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Krawczyk N, Rivera BD, Chang JE, Grivel M, Chen YH, Nagappala S, Englander H, McNeely J. Strategies to support substance use disorder care transitions from acute-care to community-based settings: a scoping review and typology. Addict Sci Clin Pract 2023; 18:67. [PMID: 37919755 PMCID: PMC10621088 DOI: 10.1186/s13722-023-00422-w] [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] [Received: 04/03/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Acute-care interventions that identify patients with substance use disorders (SUDs), initiate treatment, and link patients to community-based services, have proliferated in recent years. Yet, much is unknown about the specific strategies being used to support continuity of care from emergency department (ED) or inpatient hospital settings to community-based SUD treatment. In this scoping review, we synthesize the existing literature on patient transition interventions, and form an initial typology of reported strategies. METHODS We searched Pubmed, Embase, CINAHL and PsychINFO for peer-reviewed articles published between 2000 and 2021 that studied interventions linking patients with SUD from ED or inpatient hospital settings to community-based SUD services. Eligible articles measured at least one post-discharge treatment outcome and included a description of the strategy used to promote linkage to community care. Detailed information was extracted on the components of the transition strategies and a thematic coding process was used to categorize strategies into a typology based on shared characteristics. Facilitators and barriers to transitions of care were synthesized using the Consolidated Framework for Implementation Research. RESULTS Forty-five articles met inclusion criteria. 62% included ED interventions and 44% inpatient interventions. The majority focused on patients with opioid (71%) or alcohol (31%) use disorder. The transition strategies reported across studies were heterogeneous and often not well described. An initial typology of ten transition strategies, including five pre- and five post-discharge transition strategies is proposed. The most common strategy was scheduling an appointment with a community-based treatment provider prior to discharge. A range of facilitators and barriers were described, which can inform efforts to improve hospital-to-community transitions of care. CONCLUSIONS Strategies to support transitions from acute-care to community-based SUD services, although critical for ensuring continuity of care, vary greatly across interventions and are inconsistently measured and described. More research is needed to classify SUD care transition strategies, understand their components, and explore which lead to the best patient outcomes.
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Affiliation(s)
- Noa Krawczyk
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, 10065, USA.
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, Room 5-53, New York, USA.
| | - Bianca D Rivera
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, 10065, USA
| | - Ji E Chang
- Department of Public Health Policy and Management, NYU School of Global Public Health, New York, NY, 10003, USA
| | - Margaux Grivel
- Department of Social and Behavioral Sciences, NYU School of Global Public Health, New York, NY, 10003, USA
| | - Yu-Heng Chen
- Department of Criminal Justice, Temple University, Philadelphia, PA, 19102, USA
| | | | - Honora Englander
- Department of Medicine, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Jennifer McNeely
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, 10065, USA
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Krawczyk N, Rivera BD, Chang JE, Grivel M, Chen YH, Nagappala S, Englander H, McNeely J. Strategies to support substance use disorder care transitions from acute-care to community-based settings: A Scoping review and typology. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.24.23289042. [PMID: 37162840 PMCID: PMC10168484 DOI: 10.1101/2023.04.24.23289042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Acute-care interventions that identify patients with substance use disorders (SUDs), initiate treatment, and link patients to community-based services, have proliferated in recent years. Yet, much is unknown about the specific strategies being used to support continuity of care from emergency department (ED) or inpatient hospital settings to community-based SUD treatment. In this scoping review, we synthesize the existing literature on patient transition interventions, and form an initial typology of reported strategies. Methods We searched Pubmed, Embase, CINAHL and PsychINFO for peer-reviewed articles published between 2000-2021 that studied interventions linking SUD patients from ED or inpatient hospital settings to community-based SUD services. Eligible articles measured at least one post-discharge treatment outcome and included a description of the strategy used to promote linkage to community care. Detailed information was extracted on the components of the transition strategies and a thematic coding process was used to categorize strategies into a typology based on shared characteristics. Facilitators and barriers to transitions of care were synthesized using the Consolidated Framework for Implementation Research. Results Forty-five articles met inclusion criteria. 62% included ED interventions and 44% inpatient interventions. The majority focused on patients with opioid (71%) followed by alcohol (31%) use disorder. The transition strategies reported across studies were heterogeneous and often not well described. An initial typology of ten transition strategies, including five pre- and five post-discharge transition strategies is proposed. The most common strategy was scheduling an appointment with a community-based treatment provider prior to discharge. A range of facilitators and barriers were described, which can inform efforts to improve hospital-to-community transitions of care. Conclusions Strategies to support transitions from acute-care to community-based SUD services, although critical for ensuring continuity of care, vary greatly across interventions and are inconsistently measured and described. More research is needed to classify SUD care transition strategies, understand their components, and explore which lead to the best patient outcomes.
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Affiliation(s)
- Noa Krawczyk
- Department of Population Health, NYU Grossman School of Medicine, New York NY 10065
| | - Bianca D. Rivera
- Department of Population Health, NYU Grossman School of Medicine, New York NY 10065
| | - Ji E. Chang
- Department of Public Health Policy and Management, NYU School of Global Public Health, New York NY 10003
| | - Margaux Grivel
- Department of Social and Behavioral Sciences, NYU School of Global Public Health, New York NY 10003
| | - Yu-Heng Chen
- Department of Criminal Justice, Temple University, Philadelphia, PA 19102
| | | | - Honora Englander
- Department of Medicine, Oregon Health & Science University, Portland, OR 97239
| | - Jennifer McNeely
- Department of Population Health, NYU Grossman School of Medicine, New York NY 10065
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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.
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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
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Lowenstein M, Perrone J, Xiong RA, Snider CK, O’Donnell N, Hermann D, Rosin R, Dees J, McFadden R, Khatri U, Meisel ZF, Mitra N, Delgado MK. Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder. Ann Emerg Med 2022; 79:237-248. [PMID: 34922776 PMCID: PMC8860858 DOI: 10.1016/j.annemergmed.2021.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/15/2021] [Accepted: 10/18/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE There is strong evidence supporting emergency department (ED)-initiated buprenorphine for opioid use disorder, but less is known about how to implement this practice. Our aim was to describe implementation, maintenance, and provider adoption of a multicomponent strategy for opioid use disorder treatment in 3 urban, academic EDs. METHODS We conducted a retrospective analysis of electronic health record data for adult patients with opioid use disorder-related visits before (March 2017 to November 2018) and after (December 2018 to July 2020) implementation. We describe patient characteristics, clinical treatment, and process measures over time and conducted an interrupted time series analysis using a patient-level multivariable logistic regression model to assess the association of the interventions with buprenorphine use and other outcomes. Finally, we report provider-level variation in prescribing after implementation. RESULTS There were 2,665 opioid use disorder-related visits during the study period: 28% for overdose, 8% for withdrawal, and 64% for other conditions. Thirteen percent of patients received medications for opioid use disorder during or after their ED visit overall. Following intervention implementation, there were sustained increases in treatment and process measures, with a net increase in total buprenorphine of 20% in the postperiod (95% confidence interval 16% to 23%). In the adjusted patient-level model, there was an immediate increase in the probability of buprenorphine treatment of 24.5% (95% confidence interval 12.1% to 37.0%) with intervention implementation. Seventy percent of providers wrote at least 1 buprenorphine prescription, but provider-level buprenorphine prescribing ranged from 0% to 61% of opioid use disorder-related encounters. CONCLUSION A combination of strategies to increase ED-initiated opioid use disorder treatment was associated with sustained increases in treatment and process measures. However, adoption varied widely among providers, suggesting that additional strategies are needed for broader uptake.
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Affiliation(s)
- Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Ruiying Aria Xiong
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | | | - Nicole O’Donnell
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Davis Hermann
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Roy Rosin
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Julie Dees
- Family Service Association of Bucks County, Langhorne, PA
| | - Rachel McFadden
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Utsha Khatri
- Department of Emergency Medicine, Mount Sinai Icahn School of Medicine, New York, NY
| | - Zachary F. Meisel
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Nandita Mitra
- Department: Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - M. Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
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