Hospital-initiated interventions promote patient-centered care for people with SUDs

Patients with substance use disorders who received navigation services in the hospital through 3 months after discharge had lower rates of ED readmission vs. those who received usual care, according to recent data from a single-center trial.

The findings build on previous research demonstrating the benefits of another hospital-initiated intervention that facilitates patient-centered care for people with substance use disorders (SUDs).

“The goal of individualized case management is to address each person’s unique barriers that keep them from engaging in recommended medical care, including addiction treatment. A vexing thing about substance use disorders is that they often come with some degree of hesitancy around seeking help,” Jan Gryczynski, PhD, a senior research scientist at the Friends Research Institute in Baltimore, told Healio Primary Care. “The proactive aspect of these services is critical, because peoples’ ability and readiness to engage can fluctuate — sometimes dramatically over short periods of time.”

NavSTAR intervention

In Annals of Internal Medicine, Gryczynski and colleagues reported that many hospitals in the United States are implementing addiction consultation services “to better meet the needs of patients” with SUDs. However, they noted that additional services are needed to address barriers to follow-up care. Therefore, the researchers investigated the effectiveness of the Navigation Services to Avoid Rehospitalization (NavSTAR) intervention — a model that is “informed by patient navigation to promote engagement in care and reduce acute care use among patients seen by a hospital addiction consultation service.”

Gryczynski and colleagues conducted a single-center, two-group parallel randomized controlled trial of hospitalized adults with comorbid SUDs who were admitted to the ED of an urban academic hospital in Baltimore. The 400 participants (43% women; 55.5% Black; mean age, 45.1 years) had opioid (78.5%), cocaine (53.5%) or alcohol (35.3%) use disorders.

Among the study population, 11.5% reported full-time employment and 43% were homeless. The researchers excluded patients who were enrolled in SUD treatment within 30 days of hospital admission, did not reside in Baltimore, were pregnant, planned to discharge to a long-term care or terminal inpatient facility or who were in the hospital for a suicide attempt.

They randomly assigned patients to receive either usual care (n = 200) or usual care plus additional addiction consultation services from social workers, or “navigators,” through the NavSTAR intervention (n = 200). The intervention began at the hospital bedside for most patients, who then continued to receive consultations after discharge (n = 190). Others were first contacted in the community after discharge, and one participant did not have contact with a navigator.

Patients in the NavSTAR group reported talking to the navigator about drug and alcohol use (81%), as well as receiving help communicating with health care providers (70.6%), transportation (70.6%), setting up appointments for outpatient care (69.1%), drug or alcohol treatment (64.3%), paperwork (66.7%) and obtaining prescription medication (36.5%).

“Offering services in a proactive way ... communicates to the patient that their well-being is a priority for the care team,” Gryczynski said. “Unfortunately, many people with substance use disorders have had bad experiences with the service system due to stigma and other reasons, so being proactive with case management and practical assistance can also help to build trust.”

Over a 12-month observation period, patients in the NavSTAR group had a lower event rate per 1,000 person days for inpatient admissions, with 6.05 events vs. 8.13 events (HR = .74; 95% CI, p.58-0.96) in the control group, as well as a lower event rate for ED visits, with 17.66 events vs. 27.85 events (HR = .66; 95% CI, 0.49-0.89). Among these patients, there was also a lower likelihood of inpatient readmission within 30 days (15.5% vs. 30%; P < .001).

“Even as the intervention reduced hospital use, patients in the intervention group did not fare worse on other measures of health and functioning,” Gryczynski said.

Patients in the NavSTAR group also had a higher likelihood of entering SUD treatment within 3 months after discharge compared with patients in the control group (50.3% vs. 35.3%; P = 0.014), Gryczynski said “more research with larger samples is needed to see what other benefits this intervention might have,” but the finding on the proportion of patients who enter SUD treatment is consistent with other research.

IMPACT intervention

In a separate study published in the Journal of General Internal Medicine in 2019, Honora Englander, MD, of Oregon Health & Science University, and colleagues reported that a hospital-based intervention known as the Improving Addiction Care Team (IMPACT) — which they described as “an interdisciplinary team of addiction medicine physicians, social workers and peers with lived experience in recovery” — also was associated with improvements in SUD care. In this intervention, members of the care team offered pharmacotherapy, behavioral treatments and harm reduction services to patients with SUDs during hospitalization, then helped coordinate SUD treatment after discharge.

To evaluate the effectiveness of the intervention, Englander and colleagues matched 208 adults (61.1% men; 17.8% previously treated for SUD) who received a consultation from IMPACT with 416 controls (59.9% men; 16.8% previously treated for SUD).

The data showed that patients in the IMPACT group were more likely to receive SUD treatment after hospital discharge (38.9% vs. 23.3%; adjusted OR [aOR] = 2.15; 95% CI, 1.29-3.58). Englander and colleagues wrote that this likelihood persisted when considering only patients who did not receive SUD treatment before hospitalization (aOR = 2.63; 95% CI, 1.46-4.72).

Overall, the researchers from both studies said the findings demonstrate the benefits of additional consultation services for patients with SUDs.

Gryczynski said that primary care providers also have a “critical role” in SUD care.

“There is a great deal that primary care providers can do to support patients with SUDs, first and foremost treating SUDs directly in the primary care context,” Gryczynski said. “This includes getting training to prescribe buprenorphine, as well as strengthening referral linkages to treatment programs in the community.”

References:

• Englander H, et al. J Gen Intern Med. 2019;doi:10.1007/s11606-019-05251-9.
• Gryczynski J, et al. Ann Intern Med. 2021;doi:10.7326/M20-5475.