Predictors of Opioid and Alcohol Pharmacotherapy Initiation at Hospital Discharge Among Patients Seen by an Inpatient Addiction Consult Service

Background: Medications for opioid use disorder (MOUD) and alcohol use disorder (MAUD) are effective and under-prescribed. Hospital-based addiction consult services can engage out-of-treatment adults in addictions care. Understanding which patients are most likely to initiate MOUD and MAUD can inform interventions and deepen understanding of hospitals’ role in addressing substance use disorders (SUD). Objective: Determine patient- and consult-service level characteristics associated with MOUD/MAUD initiation during hospitalization. Methods: We analyzed data from a study of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction consult service at an academic medical center. Researchers collected patient surveys and clinical data from September 2015 to May 2018. We used logistic regression to identify characteristics associated with medication initiation among participants with OUD, AUD, or both. Candidate variables included patient demographics, social determinants, and treatment-related factors. Results: Three hundred thirty-nine participants had moderate to severe OUD, AUD, or both and were not engaged in MOUD/MAUD care at admission. Past methadone maintenance treatment (aOR 2.07, 95%CI (1.17, 3.66)), homelessness (aOR 2.63, 95%CI (1.52, 4.53)), and partner substance use (aOR 2.05, 95%CI (1.12, 3.76) were associated with MOUD/MAUD initiation. Concurrent methamphetamine use disorder (aOR 0.32, 95%CI (0.18, 0.56)) was negatively associated with MOUD/MAUD initiation. Conclusions: The association of MOUD/MAUD initiation with homelessness and partner substance use suggests that hospitalization may be an opportunity to reach highly-vulnerable people, further underscoring the need to provide hospital-based addictions care as a health-system strategy. Methamphetamine\u27s negative association with MOUD/MAUD warrants further study

The SUMMIT Ambulatory‑ICU Primary Care Model for Medically and Socially Complex Patients in an Urban Federally Qualified Health Center: Study Design and Rationale

Background: Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. Methods/design: Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: \u3e 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have \u3c 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. Discussion: The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers

The SUMMIT Ambulatory‑ICU Primary Care Model for Medically and Socially Complex Patients in an Urban Federally Qualified Health Center: Study Design and Rationale

Background: Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. Methods/design: Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: \u3e 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have \u3c 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. Discussion: The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers

Opioid Agonist Therapy During Hospitalization Within the Veterans Health Administration: a Pragmatic Retrospective Cohort Analysis

Background Hospitalization of patients with opioid use disorder (OUD) is increasing, yet little is known about opioid agonist therapy (OAT: methadone and buprenorphine) administration during admission. Objective Describe and examine patient- and hospital-level characteristics associated with OAT receipt during hospitalization in the Veterans Health Administration (VHA). Participants A total of 12,407 unique patients, ≥ 18 years old, with an OUD-related ICD-10 diagnosis within 12 months prior to or during index hospitalization in fiscal year 2017 from 109 VHA hospitals in the continental U.S. Main Measure OAT received during hospitalization. Key Results Few admissions received OAT (n = 1914; 15%) and when provided it was most often for withdrawal management (n = 834; 7%). Among patients not on OAT prior to admission who survived hospitalization (n = 10,969), 2.0% (n = 203) were newly initiated on OAT with linkage to care after hospital discharge. Hospitals varied in the frequency of OAT delivery (range, 0 to 43% of qualified admissions). Patients with pre-admission OAT (adjusted odds ratio [AOR] = 15.30; 95% CI [13.2, 17.7]), acute OUD diagnosis (AOR = 2.3; 95% CI [1.99, 2.66]), and male gender (AOR 1.52; 95% CI [1.16, 2.01]) had increased odds of OAT receipt. Patients who received non-OAT opioids (AOR 0.53; 95% CI [0.46, 0.61]) or surgical procedures (AOR 0.75; 95% CI [0.57, 0.99]) had decreased odds of OAT receipt. Large-sized (AOR = 2.0; 95% CI [1.39, 3.00]) and medium-sized (AOR = 1.9; 95% CI [1.33, 2.70]) hospitals were more likely to provide OAT. Conclusions In a sample of VHA inpatient medical admissions, OAT delivery was infrequent, varied across the health system, and was associated with specific patient and hospital characteristics. Policy and educational interventions should promote hospital-based OAT delivery

Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: a Propensity-Matched Analysis

Background Hospitalizations due to medical and surgical complications of substance use disorder (SUD) are rising. Most hospitals lack systems to treat SUD, and most people with SUD do not engage in treatment after discharge. Objective Determine the effect of a hospital-based addiction medicine consult service, the Improving Addiction Care Team (IMPACT), on post-hospital SUD treatment engagement. Design Cohort study using multivariable analysis of Oregon Medicaid claims comparing IMPACT patients with propensity-matched controls. Participants 18–64-year-old Oregon Medicaid beneficiaries with SUD, hospitalized at an Oregon hospital between July 1, 2015, and September 30, 2016. IMPACT patients (n = 208) were matched to controls (n = 416) using a propensity score that accounted for SUD, gender, age, race, residence region, and diagnoses. Interventions IMPACT included hospital-based consultation care from an interdisciplinary team of addiction medicine physicians, social workers, and peers with lived experience in recovery. IMPACT met patients during hospitalization; offered pharmacotherapy, behavioral treatments, and harm reduction services; and supported linkages to SUD treatment after discharge. Outcomes Healthcare Effectiveness Data and Information Set (HEDIS) measure of SUD treatment engagement, defined as two or more claims on two separate days for SUD care within 34 days of discharge. Results Only 17.2% of all patients were engaged in SUD treatment before hospitalization. IMPACT patients engaged in SUD treatment following discharge more frequently than controls (38.9% vs. 23.3%, p \u3c 0.01; aOR 2.15, 95% confidence interval [CI] 1.29–3.58). IMPACT participation remained associated with SUD treatment engagement when limiting the sample to people who were not engaged in treatment prior to hospitalization (aOR 2.63; 95% CI 1.46–4.72). Conclusions Hospital-based addiction medicine consultation can improve SUD treatment engagement, which is associated with reduced substance use, mortality, and other important clinical outcomes. National expansion of such models represents an opportunity to address an enduring gap in the SUD treatment continuum

Trust in Hospital Physicians Among Patients With Substance Use Disorder Referred to an Addiction Consult Service

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

“It’s Been an Experience, a Life Learning Experience”: A Qualitative Study of Hospitalized Patients with Substance Use Disorders

Background: Individuals with substance use disorders (SUD) have high rates of chronic illness and readmission, yet few are engaged in addiction treatment. Hospitalization may be a reachable moment for initiating and coordinating addiction care, but little is known about motivation for change in the inpatient setting. Objective: To explore the experiences of hospitalized adults with SUD and to better understand patient and system level factors impacting readiness for change. Design: We performed a qualitative study using individual interviews. The study was nested within a larger mixed-methods needs assessment. Participants and Setting: Hospitalized adults admitted to medical or surgical units at an urban academic medical center who reported high-risk alcohol or drug use on AUDIT-C or single-item drug use screener. Approach: We conducted a thematic analysis, using an inductive approach at a semantic level. Key Results: Thirty-two patients participated. The mean age was 43 years; 75% were men, and 68% identified as white. Participants reported moderate to high-risk alcohol (39%), amphetamine (46%), and opioid (65%) use. Emergent themes highlight the influence of hospitalization at the patient, provider, and health system levels. Many patients experienced hospitalization as a wake-up call, where mortality was motivation for change and hospitalization disrupted substance use. However, many participants voiced complex narratives of social chaos, trauma, homelessness, and chronic pain. Participants valued providers who understood SUD and the importance of treatment choice. Patient experience suggests the importance of peers in the hospital setting, access to medication-assisted treatment, and coordinated care post-discharge. Conclusions: This study supports that hospitalization offers an opportunity to initiate and coordinate addiction care, and provides insights into patient, provider, and health system factors which can leverage the reachability of this moment

Recommendations for Integrating Peer Mentors in Hospital-Based Addiction Care

Legislators and health systems have recently begun to explore the use of peer mentors as part of hospital-based addiction teams. Integrating peers into hospitals is a complex undertaking still in its infancy. Peers’ lived experience of addiction and its consequences, combined with their distance from medical culture and hierarchy, is at the core of their power – and creates inherent challenges in integrating peers into hospital settings. Successful integration of peers in hospitals has unique challenges for individual providers, health systems, and the peers themselves. We have included peers as part of a hospital-based addiction medicine team at our hospital since 2015. In this manuscript, we outline some unique challenges, share lessons learned, and provide recommendations for integrating peers into hospital-based SUD care. Challenges include the rigid professional hierarchy of hospitals which contrasts with peers’ role, which is built on shared life experience and relationship; different expectations regarding professional boundaries and sharing personal information; the intensity of the hospital environment; and, illness severity of hospitalized people which can be emotionally draining and increase peers’ own risk for relapse. Recommendations focus on establishing a way to finance the peer program, clearly defining the peer role, creating a home base within hospital settings, creating a collaborative and structured process for hiring and retaining peers, identifying peers who are likely to succeed, providing initial and ongoing training to peers that extends beyond typical peer certification, ways to introduce peer program to hospital staff, and providing regular, meaningful supervision. We hope that our recommendations help other hospital systems capitalize on the practical lessons learned from our experience

“Did I Do as Best as the System Would Let Me?” Healthcare Professional Views on Hospital to Home Care Transitions

BACKGROUND Patients are vulnerable to poor quality, fragmented care as they transition from hospital to home. Few studies examine the discharge process from the perspectives of multiple healthcare professionals. OBJECTIVE To understand care transitions from the perspective of diverse healthcare professionals, and identify recommendations for process improvement. DESIGN Cross sectional qualitative study. PARTICIPANTS AND SETTING Clinicians, care teams, and administrators from the inpatient general medicine services at one urban, academic hospital; two outpatient primary care clinics; and one Medicaid managed care plan. APPROACH We conducted 13 focus groups and two in-depth interviews with participants prior to initiating a hospital-funded, multi-component transitional care intervention for uninsured and low-income publicly insured patients, the Care Transitions Innovation (C-TraIn). We used thematic analysis to identify emergent themes and a cross-case comparative analysis to describe variation by participant role and setting. KEY RESULTS Poor transitional care reflected healthcare system fragmentation, limiting the ability of healthcare professionals to provide optimal patient care. Lack of standardized processes, poor multidisciplinary communication within the hospital, and fragmented communication across settings led to chaotic, unsystematic transitions, poor patient outcomes, and feelings of futility and dissatisfaction among providers. Patients with complex psychosocial needs were especially vulnerable during care transitions. Recommended changes to improve transitional care included improving hospital multidisciplinary hospital rounds, clarifying accountability as patients move across settings, standardizing discharge processes, and providing additional medical staff training. CONCLUSIONS Hospital to home care transitions are critical junctures that can impact health outcomes, experience of care, and costs. Transitional care quality improvement initiatives must address system fragmentation, reduce communication barriers within and between settings, and ensure adequate professional training

Understanding the Impact of the SARS-COV-2 Pandemic on Hospitalized Patients with Substance Use Disorder

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\u27 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