Reducing the risk of readmission by talking about substance abuse before discharge

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 long-term 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.