BMC Pilots Training Program to Improve Post-Acute Care for Patients with Substance Use Disorder

At Boston Medical Center (BMC), one in three patients admitted to the hospital has a substance use disorder (SUD). After hospitalization for common health conditions related to substance use such as endocarditis, cellulitis or physical injuries, patients often require specialized nursing care or physical therapy in a rehabilitative facility. However, according to a recent article published in the Journal of Addiction Medicine, most BMC patients with SUDs are rejected from skilled nursing facilities, which needlessly extends costly in-patient care or leaves patients to return home without care services.

To improve post-acute care acceptance rates and overall quality of care for this patient population, a new BMC pilot program will partner with skilled nursing facilities to reduce discrimination and increase acceptance rates of patients with SUD.

History of Discrimination at Skilled Nursing Facilities

In recent years, healthcare companies have come under fire for refusing to accept patients on buprenorphine or methadone treatment in their skilled nursing facilities. The U.S. Attorney’s Office has settled several disputes against Massachusetts companies claiming their discriminatory practices violate the Americans with Disabilities Act. But settlements requiring companies to change discriminatory practices have done little to change the reality for people on medications for opioid use disorder (MOUD) needing post-acute care.

A study led by Simeon Kimmel, MD, MA, that tracked referral acceptance rates of BMC patients to post-acute medical care facilities found that 83.3 percent of referrals for individuals with opioid use disorder were turned down, compared to 65.5 percent of those without opioid use disorder. Zoe Weinstein, MD, director of Inpatient Addiction Consult Service at BMC, sees the effects of discrimination firsthand. She believes it perpetuates stigma among patients and caregivers and can disrupt long-term care goals.

 “As a primary care doctor of some of these patients, I see how devastating it is for them to feel that stigma and rejection,” says Dr. Weinstein. “Sometimes patients will request to be taken off medication so they can go to a certain facility, or sometimes we’ll even have staff say, ‘can’t you just take the patient off this medication so they can go to a facility?’ You would never say can you take the patient off insulin, blood pressure medicine or aspirin. Even considering stopping medication undermines their medical care.”

BMC to Extend Addiction Treatment Education to Post-acute Care Facilities

Thanks to a grant from the Grayken Center for Addiction, Dr. Weinstein and her colleagues are launching a one-year pilot program to provide skills, knowledge and resources on SUD treatment to participating post-acute care facilities. Through monthly scheduled educational sessions, the multidisciplinary team plans to cover core topics of SUD care, such as the fundamentals of medications for opioid disorder, methadone clinic logistics, pain management and discharge planning. According to Dr. Weinstein, building skills and confidence among staff and implementing a few simple solutions could considerably improve facilities’ acceptance rates.

“Facilities can pursue easy solutions to better accommodate patients with SUDs. They need to employ interventions like making sure they have someone on staff who is capable of prescribing MOUD, or transporting the patient to appointments or to the methadone clinic to get their doses or working with the methadone clinic to get the medication for the patient and securely storing those bottles on site,” she explains.

Dr. Weinstein also hopes the pilot—which will first focus on two or three individual facilities in the Boston area—will have a compounding effect across the region.  

“Many of these skilled nursing facilities are part of larger corporate health systems, but they also have their own unique culture, staff and local leadership. While we plan to treat each nursing facility as an individual unit, we hope there will be a spillover effect. If one facility that is part of a larger corporation actively participates, hopefully, that place will become a pilot that illustrates success with this patient population and rolls out effective interventions to other partner facilities.”

Massachusetts currently has the second-highest rate of opioid-related hospitalization in the country. While extended in-patient hospital stays allow physicians to initiate MOUD, maintaining treatment and coordination of care for people with SUDs in rehabilitative settings could significantly improve patient outcomes. The new training program will complement other ongoing education and advocacy work at the Grayken Center for Addiction to improve acceptance rates at skilled nursing facilities and overall continuity of care for people with SUDs.