Opioid use disorder (OUD), like other chronic diseases, requires ongoing treatment. Yet, people with OUD continue to face stigma and barriers to health care that can interrupt their treatment and imperil their recovery. New research from Boston Medical Center’s Grayken Center for Addiction finds patients hospitalized with OUD are rejected more than twice as often as patients without OUD when referred to a post-acute care facility for continuing care, such as a skilled nursing or sub-acute nursing facility.
Published in a March issue of Health Affairs, the study compared post-acute care placements for hospitalized patients with OUD with patients who are not diagnosed or treated for OUD.
“The finding that hospitalized individuals with OUD are routinely rejected from post-acute medical care in Massachusetts and New Hampshire and are more likely to be rejected than people without OUD should be alarming to policymakers, civil rights advocates, health care system leaders, clinicians and people with OUD across the country,” said Simeon Kimmel, MD, MA, an addiction medicine and infectious diseases specialist at the Grayken Center, who serves as the study’s corresponding author. “To ensure that people with OUD have equitable access to post-acute care, it’s critical that state and federal governments enforce guidelines on equity and that nursing facilities follow them.”
Discrimination Against Patients with OUD
In 2016, the Massachusetts Department of Public Health issued guidelines to all state-licensed facilities that people with OUD should not be excluded from admission to post-acute care due to treatment with medications for opioid use disorder, such as methadone or buprenorphine. However, the U.S. Attorney’s office for the District of Massachusetts has reached settlements with several post-acute care medical facilities for violating the Americans with Disabilities Act (ADA) by screening out individuals with OUD or those treated with medication for OUD.
Anecdotally, clinicians have reported difficulty discharging patients with OUD to post-acute care, but few studies have systematically evaluated post-acute care referral and admissions practices. This new study examined 2,463 hospitalizations at Boston Medical Center that resulted in 16,503 referrals to 244 private post-acute care facilities in Massachusetts for one year, from January 1, 2018, to December 31, 2018.
Some of the study's key findings:
- Only 6 in 10 patients with OUD were ultimately discharged to a nursing facility, meaning many faced longer hospital stays or discharges without care in a post-acute facility.
- 83.3percent of referrals for individuals with OUD were turned down, compared to 65.5 percent of those without OUD.
- Hospitalized individuals with OUD were referred to more facilities than those without OUD (8.2 vs 6.6).
- Facilities that accepted OUD referrals at higher rates were significantly less likely to be ranked as above-average facilities by the Centers for Medicare & Medicaid Services (with fewer than four or five stars in CMS ratings).
To ensure that people with OUD have equitable access to post-acute care, it’s critical that state and federal governments enforce guidelines on equity and that nursing facilities follow them.Click To Tweet
Continuity of Care Is Critical for OUD Treatment
Massachusetts has the second-highest rate of opioid-related hospitalization in the country, making discharge planning critically important. Patients with OUD may be hospitalized for complications associated with opioid use, including systemic infections from drug injections, overdoses, physical and psychological traumas, strokes, and other acute conditions such as pneumonia or chronic obstructive lung disease.
After stabilization in an acute-care hospital, patients with OUD commonly require care in a post-acute facility for intravenous antibiotics, wound care, medication titration, and physical or occupational therapy.
This new research in Health Affairs follows a 2020 study from the Grayken Center for Addiction in the Journal of Addiction that found 29 percent of private post-acute care facilities in Massachusetts explicitly discriminated against individuals with OUD by rejecting their referrals explicitly because of an OUD diagnosis or use of medication for OUD. Rejections for those specific reasons have been classified as discriminatory under the ADA and also violate Massachusetts policies.
“The results of this study go further and demonstrate that referral, rejection and acceptance inequities for people with opioid use disorder are widespread and not limited to referrals for individuals with OUD where explicit discrimination was documented,” said Kimmel, also an assistant professor of medicine at Boston University School of Medicine. “The post-acute care facilities in this study disproportionally reject individuals with OUD from medically necessary care despite public health guidelines and legal scrutiny.”