Published in the August 2017 issue of Today’s Hospitalist
LIKE MANY HOSPITALS around the country, Oregon Health & Science University (OHSU) in Portland admits a lot of patients with substance use disorders. Lengths of stay can soar in these patients, and many bounce back weeks or months later in similar or worse shape.
That’s why in 2014, the 522-bed academic center sought a better way to care for these patients. The goal was to identify care gaps and to treat patients’ addiction in the hospital, not just manage their withdrawal.
The resulting program—the Improving Addiction Care Team (IMPACT)—marries inpatient addiction consultation with rapid access to post-discharge treatment. In developing the outpatient component, OHSU has developed relationships with local treatment organizations and rural programs to find resources for patients who live outside Portland.
“We were failing people hospitalized with medical complications of addiction.”
According to a report about IMPACT in the May issue of the Journal of Hospital Medicine, the program’s goal is to take advantage of “reachable moments” in a hospitalization to initiate treatment and referral.
Systems and expertise
A needs assessment done prior to implementing IMPACT found that a majority of inpatients with substance use disorders were interested in either quitting or cutting back, and that many wanted to start medications for addiction in the hospital. Patients also reported inadequate withdrawal treatment, a lack of trust in health care providers and long wait times to enter post-discharge programs.
“Before IMPACT, we were failing people hospitalized with medical complications of addiction,” says Honora Englander, MD, the hospitalist and addiction medicine physician who designed the initiative and led its implementation. “We didn’t have the expertise or the systems in place to address their underlying substance use disorder.”
In addition to not connecting patients to treatment, “we also weren’t initiating medication for addiction in the hospital because we didn’t have the right expertise or the care pathways to support continuing care.”
With IMPACT, inpatients who self-report substance use are approached by a social worker or peer mentor to gauge their interest in treatment. (The hospital-based peers, who are an important part of IMPACT, are also in recovery.) The addiction medicine physician consults and advises on withdrawal and pain management and helps initiate medications like methadone or suboxone, if appropriate. Before IMPACT, OHSU did not have an addiction medicine service.
Original program staffing was fairly slim: a 0.5 FTE physician, one FTE social worker and a 1.4 FTE peer mentor. Currently, the program includes 1.5 FTE physicians (divided among five doctors), two FTE social workers, one FTE nurse practitioner and two FTE peers.
The peers work weekdays and are available by phone on evenings and weekends. In addition, the program employs what it calls an “in-reach liaison” (0.5 FTE), a staff person from an OHSU community site who performs in-hospital assessment to triage patients and coordinate outpatient care.
Community partnerships, Dr. Englander points out, have been critical to reducing long wait times post-discharge. And peers support patients throughout their hospital stay and after they leave.
“Patients interact with peers in a way that’s totally different from how they would with physicians,” she explains. “Peers understand what it feels like to go through withdrawal, be in jail or live in the streets.” Further, “they help build trust and understanding, which is critical to having patients engage with our team.”
IMPACT grew in part out of Dr. Englander’s earlier work developing and leading OHSU’s Care Transitions Innovation (C-TraIn) program. That initiative focuses on hospital-to-home transitions for low-income adults, particularly uninsured patients and those on Medicaid—many of whom have substance use disorders. When Dr. Englander and her colleagues began developing outpatient resources for IMPACT, their C-TraIn experience was invaluable.
The task force that helped launch IMPACT included hospitalists, infectious disease and addiction medicine physicians, nursing and social work leadership, and health services researchers. Regional stakeholders included payers, charitable organizations and substance use disorder treatment centers, as well as primary care and community health centers.
Dr. Englander and her team also made the business case to hospital administrators and payers. Data from 165 participants in the original needs assessment revealed 137 readmissions over 4.5 months, with a mean cost per readmission of $31,157. Charges ran as high as $68,774 for patients with endocarditis or osteomyelitis.
“We estimated that IMPACT could reduce six-month readmissions by 10%, potentially avoiding $674,863 in charges,” says Dr. Englander. She and her colleagues used a conservative LOS reduction of 10%—which equaled 205 bed days—for budgeting purposes. The financial model also assumed that 15% of OHSU’s inpatients have substance use disorders, a figure based on administrative data that is likely low.
Another factor that bolstered the rationale for IMPACT was the state’s Medicaid system. In 2012, Oregon transformed Medicaid by establishing regional coordinated care organizations to slow spending and improve outcomes. Under that model, hospitals take on some financial risk while working to strengthen outpatient support for Medicaid patients.
Dr. Englander points out that programs like IMPACT are increasingly important. The opioid epidemic has hit her state hard, with opioid-related hospitalizations there increasing 88.9% between 2009 and 2014. Many patients also aren’t able or ready to access treatment through primary care or the community.
So how has IMPACT performed? In 2016, the program saved more than 400 hospital days. When 2016 Medicaid data become available, OHSU expects to see reduced readmission rates.
Funding, logistical challenges
To date, OHSU has assumed the majority of IMPACT’s costs, most of which go to salaries. The state’s Medicaid program has contributed some funding, and OHSU is working with two local coordinated care organizations to define a case rate for IMPACT patients. In hindsight, Dr. Englander says, it might have helped to involve payers earlier in the process.
“There really aren’t payment models that support this,” she says, despite the program’s promising return on investment. “We’ve had to work very hard to ensure sustained financial support.”
The program did terminate one early component: medically-enhanced residential treatment for patients with a substance use disorder who needed prolonged IV antibiotics. That model tested integrating home-infusion and infectious diseases care to address conditions like endocarditis in residential treatment.
And while Dr. Englander “strongly encourages” hospital systems to consider integrating peers into inpatient addiction teams, peers might not pass traditional hospital-employment background checks.
The peers working with OHSU are employed by an outside agency. According to Dr. Englander, hospitalists and health systems interested in developing similar programs should engage human resources, public safety and legal departments early on to pave the way and avoid problems.
She also notes that the center’s hospitalists and nurses give IMPACT top marks. “By building systems of care and having the right expertise onsite, patients are getting better care,” she notes. “Our providers report a tremendous amount of relief.”
Bonnie Darves is a freelance health care writer based in Seattle.