Re­duc­ing risk of read­mis­sion by talk­ing about sub­stance abuse be­fore dis­charge

Modern Healthcare - - Best Practices - By Maria Castel­lucci

Treat­ing pa­tients with sub­stance abuse dis­or­ders can be chal­leng­ing— and costly—for most hos­pi­tals.

Part of the prob­lem is the de­liv­ery sys­tem has his­tor­i­cally viewed sub­stance abuse and men­tal health as sep­a­rate from phys­i­cal health. That’s not the case. In 2014, 42.4% of 27.8 mil­lion hos­pi­tal stays for a phys­i­cal health prob­lem had a co-oc­cur­ring men­tal health or sub­stance abuse con­di­tion, ac­cord­ing to the Agency for Health­care Re­search and Qual­ity.

And read­mis­sion rates for pa­tients with sub­stance abuse dis­or­ders range from 18% to 26%, ac­cord­ing to an Au­gust 2017 study in the Amer­i­can Psy­chi­atric As­so­ci­a­tion’s jour­nal Psy­chi­atric Ser­vices.

De­spite the prob­lem’s preva­lence, most hos­pi­tals don’t have the re­sources to care for pa­tients with sub­stance abuse dis­or­ders, said Dr. Melissa Weimer, an ad­dic­tion medicine physi­cian at Yale New Haven (Conn.) Health Sys­tem. Only in the last few years has ad­dic­tion been rec­og­nized as a med­i­cal con­di­tion so most hos­pi­tals face a short­age of providers or so­cial work­ers who spe­cial­ize in the treat­ment, she said. In fact, the Amer­i­can Board of Med­i­cal Spe­cial­ties has only rec­og­nized ad­dic­tion medicine as a sub­spe­cialty since 2016.

Con­cerned about scarce re­sources to help in­pa­tients with sub­stance abuse, Yale New Haven re­cruited Weimer ear­lier this year to launch the Ad­dic­tion Medicine Con­sult Ser­vice. The pro­gram, which of­fi­cially be­gan in Oc­to­ber, of­fers in­pa­tients com­pre­hen­sive ad­dic­tion medicine ser­vices be­fore they are dis­charged as well as a longterm plan for when they re­turn home.

A sim­i­lar, long-stand­ing pro­gram was al­ready op­er­at­ing in Yale’s emer­gency de­part­ment. It’s staffed with

ad­dic­tion medicine spe­cial­ists and health pro­mo­tion ad­vo­cates who re­fer pa­tients to ser­vices in the com­mu­nity.

“We’ve done a great job in the ED, but when peo­ple ended up in the in­pa­tient unit, that wasn’t the case. I was con­cerned about it,” said Dr. Gail D’Onofrio, physi­cian-in-chief of emer­gency ser­vices at Yale New Haven Hos­pi­tal.

The Ad­dic­tion Medicine Con­sult Ser­vice at Yale is one of a grow­ing num­ber of such pro­grams in the U.S. Weimer helped Ore­gon Health & Sci­ence Univer­sity start a sim­i­lar pro­gram in 2015.

“Ser­vices such as this try to break down bar­ri­ers,” Weimer said. “We are go­ing to bring treat­ment to you in the hos­pi­tal where you are more re­cep­tive and mo­ti­vated. We can ini­ti­ate treat­ment, not just give you a pam­phlet.”

The pro­gram has been ini­tially rolled out at Yale New Haven Hos­pi­tal’s St. Raphael Cam­pus. It in­volves a physi­cian or sur­geon at the hos­pi­tal speak­ing with the pa­tient about their sub­stance abuse and Yale’s Ad­dic­tion Medicine Con­sult Ser­vice. If the pa­tient is re­cep­tive, Weimer or a mem­ber of the ad­dic­tion medicine team meets with the pa­tient one-on-one to dis­cuss the pro­gram.

“The way we ap­proach the pa­tient is non­judg­men­tal, so the pa­tient feels com­fort­able shar­ing. We are in­ten­tional about our com­mu­ni­ca­tion and the lan­guage we use,” Weimer said.

De­pend­ing on the dis­or­der, there are sev­eral treat­ment paths. For in­stance, for pa­tients with opi­oid abuse dis­or­der, a for­mal di­ag­no­sis is made af­ter a full sub­stance abuse his­tory as­sess­ment is con­ducted. Then, all the med­i­ca­tions the pa­tient takes are re­viewed to un­der­stand if any com­pli­cate or con­trib­ute to the dis­or­der. Three treat­ment of­fers are then of­fered. If the pa­tient is open to med­i­ca­tion, one of three fed­er­ally ap­proved opi­oid dis­or­der drugs are pre­scribed and started in the hos­pi­tal. For pa­tients un­re­cep­tive to med­i­ca­tions, the pa­tient is usu­ally re­ferred to a nee­dle ex­change or of­fered a nalox­one res­cue kit. Ef­forts are made for all pa­tients to re­ceive on­go­ing treat­ment in the com­mu­nity af­ter dis­charge.

Weimer is new to New Haven, so she’s spent the last sev­eral months get­ting to know the lo­cal com­mu­nity providers. “It’s im­por­tant that I have been to the place I’m re­fer­ring the pa­tient to so I can di­rectly re­as­sure the pa­tient it’s a nice place,” she said.

She’s also been mak­ing the rounds in the hos­pi­tal, in­tro­duc­ing her­self to the physi­cians and nurses so they know the ser­vice is avail­able to them. The pro­gram has been well-re­ceived by doc­tors.

“One of the pri­mary drivers for this ser­vice was the hos­pi­tal­ists say­ing they needed ex­tra sup­port around car­ing for this pop­u­la­tion. So many of them noted that this was a gap in care and it was a source of real frus­tra­tion to not have a lot of re­sources around this,” she said. ●

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