Skilled nursing facilities (SNFs) are constantly being asked to expand their capacities to care for populations they were never intended to treat. Think back to when subacute rehabilitation first arrived, and SNFs geared up to provide short-term rehabilitation. What about HIV/AIDS, chronic mental illness, and ventilator units? These are all populations that SNFs initially struggled to care for, but over time, many now provide excellent care for these residents.
Should substance use disorders (SUDs) be next on the list?
The short answer is: SNFs may have to step up. Just as there are no longer any facilities that provide longer-term care for people with a combination of medical disorders and chronic mental illness, there is no place in the larger health care system for the treatment of people with medical and substance misuse issues. Once again, SNFs are being asked to embrace a population that they have little history of caring for. But the job may turn out to be less onerous than facilities fear.
The Challenge
Many SNFs are understandably reluctant to admit residents with SUDs, expressing concerns such as:
- “These residents are younger, more physically able, and more ambulatory than my other residents—how can my staff manage them and ensure that my other residents are safe?”
- “These residents may leave the facility on a regular basis, doing who knows what in the community, and I can’t stop them from leaving.”
- “Their visitors can bring drugs and alcohol into the facility, which puts my residents and the facility at risk.”
- “A lot of them smoke, and they can be noncompliant and aggressive.”
- “When their medical issues resolve, there is no place to discharge them to.”
Some of these concerns are based in reality, while others highlight the ever-present stigma that people with SUDs face in every sphere of life. For example, residents with SUDs are actually much less likely to exhibit aggressive behaviors than residents with dementia.
The reluctance to treat the SUD population generally manifests itself in the refusal to admit these residents. In other scenarios, it results in a “Don’t ask, don’t tell” philosophy, in which residents who may be suspected of having substance misuse issues are admitted, but the disorder is not screened for, properly diagnosed, or treated. Which is worse?
A Vital Role
The fact is SNFs are actually in a good position to become a valuable asset in the national strategy to treat SUDs and can play a vital role in the fight to combat the opioid overdose epidemic.
Patients with opioid use disorder who are being discharged from hospitals are at extremely high risk for overdose and death if they are not transitioned into a program that includes Medication Assisted Treatment (MAT), and SNFs that can provide such treatment for patients in post-acute rehabilitation would prove invaluable in avoiding these tragic outcomes.
On long term care units, residents who were able to attain their highest level of physical and emotional well-being while maintaining a stable recovery from substance misuse may find themselves with their best possible chance for long-term recovery and eventually return to the community.
Post-acute care is already grappling with its own opioid issues. According to a 2017 study published in the Journal of the American Geriatrics Society, about one in seven long term care residents is being prescribed opioids in SNFs. This state of affairs is likely to get worse before it gets better, with ever-growing percentages of older Americans misusing alcohol and other drugs. A 2016 report from the Office of Inspector General for the U.S. Department of Health and Human Services found that about a third of all Medicare beneficiaries received at least one opioid prescription in 2015.
If further incentive is needed, consider that SNFs that discriminate against people in recovery from substance misuse may be violating the Americans with Disabilities Act. The bottom line is that SNFs are already treating people with SUDs, managing others on high levels of opioids, and adept at learning how to treat new populations.
Given these factors, SNFs that take a proactive approach to treating SUDs will find themselves ahead of the curve, and with their beds full, because hospitals and other components of the health care system find it extremely difficult to place these patients. Facilities taking a proactive approach will improve their census, create new referral sources, and create sorely needed environments for patients in recovery.
Following are guidelines for the care of patients with
SUDs.
Do Ask, Do Tell
One of the unfortunate and paradoxical side effects of the stigma against substance misuse is a frequent squeamishness about asking patients their historical and current substance use. If patients sense it’s a taboo subject for their health care provider, it inhibits an honest exchange of information.
In contrast, when clinicians convey that their patients’ substance use is simply one of many issues they want to know about and expect to treat, patients respond very differently. They come to understand they can expect judgment-free help with substance use issues as part of their overall plan of care. For example, imagine a patient on a short-term rehabilitation unit thinking to himself, “Hmm, this place is not only going to treat my endocarditis, it’s also going to stabilize me on Suboxone so that I can return home with a stable and healthy recovery well underway.”
Screen for Substance Misuse
A good way to get started is to screen new admissions for substance misuse. The gold standard here is called SBIRT, which stands for Screening, Brief Intervention and Referral for Treatment. Patients who trigger on a brief questionnaire would be given the “brief intervention,” which is often some type of Motivational Interviewing (MI).
MI is a technique that all health care providers, not just psychologists, can learn to do. It’s designed to explore a person’s readiness to change any behavior, not just substance abuse—so having staff members who learn the technique will pay dividends in other arenas as well, including residents’ noncompliance with diet, exercise, participation in physical therapy, and other domains.
Those residents who have a substance misuse issue and are interested in getting help would then be referred to treatment, either within the facility or through an actual referral.
Get Ready for MAT
For many years, there were no addiction-specific medications beyond methadone, which can only be prescribed for addiction in licensed clinics. That all changed with buprenorphine, which is the medication of choice for opioid use disorder. Although it’s easy for any physician, and nurse practitioners in many states, to take the training that gives them a buprenorphine waiver to prescribe it, few doctors have obtained it.
Part of the reason is physicians’ concerns that their practices would be over-run with opioid users.
But that issue doesn’t apply to post-acute providers. A SNF doctor who is able to prescribe buprenorphine (there are several brand names and formulations but the most commonly used is Suboxone) would be an asset to multiple SNFs with significant volumes of residents in recovery from opioid misuse. There are other MAT medications, particularly Vivitrol, that clinicians should become familiar with.
Review Current Opioid Prescribing Practices
Doctors are constantly evaluating the cost-benefit of treating pain (the Fifth Vital Sign) with opioids. The overzealous prescribing of opioid pain medications is the single most powerful driving force behind the opioid epidemic. Prescribing practices have begun to change, in part because of Prescription Drug
Monitoring Programs and providers’ concerns about enforcement.
Taking a mindful look at current opioid use among existing residents, with an emphasis on avoiding new opioid orders or increasing existing dosages, is a good place for facilities to start preparing to care for residents who will present for treatment with a pre-existing relationship to opioids.
Explore Alternatives to Opioids for Pain
In addition to non-opioid medications for pain management, a range of nonpharmacologic interventions are effective in the management of pain and the reduction of opioids for pain relief. Facilities that have psychologists should look at cognitive behavioral therapy, relaxation training, psychoeducation, mindfulness meditation, and hypnosis, all of which have been proven effective as part of a multifaceted pain management program. Rehabilitation and therapeutic recreation staff can design physical therapy, exercise, and stretching programs to restore function and alleviate pain.
In the long run, interdisciplinary collaboration that moves facilities away from using opioids as a default response to pain will benefit residents clinically and pay financial dividends compared with the cost of routinely treating pain with expensive medications.
Treat in-house
SNFs with MAT prescribers and consulting psychologists likely have the resources in place to provide excellent care to residents with SUDs.
Since substance misuse is found in almost every clinical population and age group, most clinical psychologists will have the requisite experience and training to work with patients presenting with substance misuse issues in the context of other psychiatric and medical problems. Facilities with MAT prescribers that don’t have psychologists can connect with state-licensed treatment facilities in the community.
Culture Change for SUDs
Another pernicious impact of the stigma surrounding substance misuse is that staff members may have erroneous beliefs and unwarranted fears about caring for the population. They may feel unprepared to provide good care or are concerned that they won’t be able to identify the signs and symptoms of substance use. That’s where staff training and education become vital.
Language Change is Crucial
Imagine someone with diabetes being informed by a health care professional that their A1C was “dirty” because they’ve been eating too much sugar. Similarly, SNFs don’t accuse people with eating disorders of engaging in food “abuse.” Human beings behave in any number of ways that are deleterious to their health—diet, lack of exercise, noncompliance with treatment, and so on—but only in substance misuse is the historical language of stigma and shame imbedded in the way people describe and work with this population.
As a profession, clinicians acknowledge that SUDs are medical conditions that require treatment and that people do recover with proper treatment, and yet the lexicon around these issues has been slow to change.
Words like “addict” and “alcoholic,” which define individuals based on one aspect of their biopsychosocial functioning, should lose their place in the health care system, as should terms like substance “abuse,” “dirty” urines, and treatment “failures,” as when used to describe a person in recovery who has had a relapse.
Forge Collaborative Relationships
As previously mentioned, SNFs that step up to provide care to SUD populations are going to become very popular, very quickly. As hospitals, primary care providers, patients’ families, and others in the community recognize a facility’s ability to successfully treat these populations, there will be an increase in referrals from those who previously struggled to find appropriate placements for these individuals.
Treating the SUD population in SNFs will require collaboration with acute care hospitals, outpatient programs, pharmacies, and other health care providers and will, in turn, create as many opportunities.
With respect to the opioid epidemic specifically, facilities that embrace SUD treatment can prove a meaningful part of the solution to a longstanding national emergency. Any facility that rises to the occasion will be identified as innovative and rewarded with a healthy census and new partner relationships.
Richard Juman, PsyD, is the national director of psychological services for TeamHealth. He can be reached at richard_juman@teamhealth.com.