Employees notion and restricted assets frustrate nursing house take care of substance abusers

A federal push to use skilled nurses to care for more patients with drug and opioid use disorders faces major systemic hurdles, researchers reported this week.

Nursing home staff feel unprepared to treat patients with SUD and OUD, have critical perceptions of addiction and complain of an overall lack of resources for addiction treatment, researchers reported this week.

“The stigma surrounding residents with SUD/OUD exacerbates health disparities for an already vulnerable group with higher rates of comorbidities such as pain, polypharmacy and geritarosis syndromes that require post-acute care,” wrote researchers from the University of Chicago and the Vanderbilt University The Journal of Addiction Medicine. “Standardized care protocols and staff training will be critical to closing gaps and increasing capacity to serve populations in care homes.”

While refusals for drug addiction are prohibited by the Americans with Disabilities Act, a study earlier this year put the refusal rate for hospital referrals at 40%. CMS has made improving access to SUD prevention, treatment and recovery services one of its key behavioral health goals.

But interviews with 24 administrators and staff from 11 qualified care facilities in the Chicago area, presented in the study published online Wednesday, show there is still a long way to go in the long-term care sector.

Four of the 11 facilities had formal programs for residents with a history of addiction that required the patient to sign a code of conduct prohibiting any illegal drug use. Five other accepted patients with diagnosed addictions but did not have structured treatment programs.

Across all facilities, residents with histories of substance abuse were generally perceived as “bad behavior” or “resource deprivation” by other residents. Other concerns were that they would be time-consuming, manipulative, aggressive, or violent, and would be exacerbated in settings with low staff-to-resident ratios, the researchers noted.

Admissions decisions in some institutions appear to be influenced by these perceptions.

“A common theme that emerged from the eligibility review centered on the perceived suitability of this population and the risk to the facility, staff and other residents,” the researchers wrote. “Many administrators expressed distaste for a ‘mixture’ of the population…. Some staff have expressed concern about the possibility of residents continuing to use or becoming aggressive and agitated, posing an individual risk to the safety of staff and other residents.”

A growing challenge

Some facilities also showed a preference for immobile and more dependent substance users. Some operators said they require toxicology reports before admitting residents, while others said “inadequate” reimbursement for residents with additional diagnoses was a potential barrier to admission.

The same applied to the procurement and administration of drugs for the treatment of addictions. Many facilities did not have a doctor on staff authorized to prescribe buprenorphine, and methadone cannot be supplied to nursing homes.

Most also did not have the behavioral health resources needed to access regular methadone treatment or even routine counseling.

However, almost all respondents acknowledged that SUD patients represent a growing long-term care population. The researchers noted that between 2013 and 2015 there was a 53 percent increase in older adults seeking treatment for opioid use disorder, and that older adults with opioid-related hospitalizations were more likely to be discharged into nursing homes than those hospitalized for other reasons became.

Policy revisions and education — especially for the nation’s geriatricians — are key to better managing SUD care, said the researchers, led by Vanderbilt’s Stacie Levine, MD.

“It is imperative not only to develop standardized training and care policies for staff to improve quality access to care for this population, but also to advocate for a thoughtful and compassionate policy shift that enables care homes to provide their residents with the best possible care to offer care.”

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