BOSTON – Patients hospitalized with opioid use disorder (OUD) are rejected more than twice as often as patients without OUD when they are referred for placement to a post-acute care facility for continuing care, such as a skilled nursing or sub-acute nursing facility, a new study from Boston Medical Center’s Grayken Center for Addiction has found.

The study, published in the March issue of Health Affairs, is one of the first to compare 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 policy makers, 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.”

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. 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. The 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 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.
  • 83.3 percent 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).

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 include systemic infections from drug injections, overdoses, physical and psychological traumas, strokes, as well as 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.”

 

About Boston Medical Center:

Boston Medical Center (BMC) is a private, not-for-profit, 514-bed, academic medical center that is the primary teaching affiliate of Boston University School of Medicine. It is the largest and busiest provider of trauma and emergency services in New England. BMC offers specialized care for complex health problems and is a leading research institution, receiving more than $166 million in sponsored research funding in fiscal year 2019. It is the 13th largest funding recipient in the U.S. from the National Institutes of Health among independent hospitals. In 1997, BMC founded Boston Medical Center Health Plan, Inc., now one of the top ranked Medicaid MCOs in the country, as a non-profit managed care organization. Boston Medical Center and Boston University School of Medicine are partners in Boston HealthNet – 12 community health centers focused on providing exceptional health care to residents of Boston. For more information, please visit http://www.bmc.org.

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