SNF opioid problems didn’t end after prosecutions began – McKnight’s Long Term Care News

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Despite a string of costly legal settlements over patients rejected for opioid use disorder, the author of a new study proving widespread admission denials says nursing homes still “have a lot of work to do.”

Nearly 40% of hospitalized opioid use disorder (OUD) patients at a major Massachusetts hospital referred for post-acute care never found a placement, according to research published Monday in Health Affairs.

“We have a lot of work to do to address what amounts to normalized discrimination against people with OUD,” lead researcher Simeon D. Kimmel, MD, assistant professor at Boston University School of Medicine, told McKnight’s. “We need continued and increased enforcement of anti-discrimination laws so that facilities understand these admission policies will not be tolerated. We need to train clinicians in post-acute care facilities to care for people with OUD — a common and treatable disease.”

For their analysis, Kimmel and colleagues examined 16,503 referrals by Boston Medical Center to 244 facilities in Massachusetts and New Hampshire in 2018. That was two years after the Massachusetts Department of Health issued guidance to all state-licensed facilities that people with OUD should not be excluded from admission because they needed treatment with medications such as methadone or buprenorphine.

The researchers found the number of rejections in 2018 demonstrated widespread inequities in “referral, rejection, and acceptance of people with OUD,” a problem likely replicated beyond Massachusetts.

“We need more data, but my guess is that access is even more limited in states where there has not been increased attention or any enforcement of federal regulations,” Kimmel said.

Overall, 83.3% of referrals for OUD patients in the Massachusetts study were rejected at least once, versus 65.5% of the broad referral group. But whereas most patients ultimately found a placement, 44.5% of OUD patients were rejected at least five times. And 38% of referred OUD patients were never discharged to a post-acute care facility.

Since that time, federal prosecutors in New England have run a targeted campaign on the issue, reaching at least nine settlements with providers large and small for violations of the Americans with Disabilities Act

Kimmel said he would like to see research using more recent data to determine what effects such tactics have had on denials. As a clinician, he’s not hopeful given the nation’s opioid crisis.

“There are a small number of facilities who accept patients with opioid use disorder who are treated with buprenorphine and a smaller number who accept patients treated with methadone,” he said. “The bed crunch with COVID and the impact of COVID on post-acute care facilities in some ways has made this problem even greater.”

Acceptance tied to quality

The facilities most likely to get referrals for and accept patients needing medication-assisted treatment were also more likely to have Centers for Medicare & Medicaid Services quality ratings of three stars or less.

“These facilities may offer specialized services or access to specialists for people with OUD,” they wrote. “As these referrals are for medical indications for patients with OUD and not OUD-specific care, this raises concerns about the quality of post-acute care for these patients.”

In addition, the researchers found 32% of post-acute facilities that received other types of referrals were not sent a single OUD-related referral, which they said was “particularly problematic and suggestive of an underlying disparity.”

The researchers found other factors associated with an increased risk of post-acute rejection included: having an alcohol use disorder, homelessness; and receiving a psychiatric consult during hospitalization. Those over 55, females and patients covered by Medicare had less chance of being rejected.

Concerns about legal footing

Providers have for years argued that they are stuck between clashing federal rules and regulations when attempting to care for patients in need of medication-assisted treatment.

“We believe every person deserves access to high-quality, long-term and post-acute care,” the American Health Care Association / National Center for Assisted Living said in response to the study Monday night. “We do not condone any type of discrimination, and we agree it is important for patients with OUD to have access to good care. At the same time, long-term care facilities must adhere to government requirements, and CMS specifically prohibits nursing homes from accepting patients for whom they cannot provide appropriate care.”

In his comment to McKnight’s, Kimmel added that changing regulations that limit access to methadone and buprenorphine in post-acute care facilities “would be a big step forward.”

In 2019, Johns Hopkins University researchers called on the federal government to change its regulations to allow for the continued use of methadone for OUD treatment in SNFs. This would include cases in which methadone use was initiated during a hospitalization. 

“DEA regulations prohibit skilled nursing facilities from starting methadone treatment on their own or continuing methadone treatment initiated during a preceding hospitalization without enrollment in an opioid treatment program,” Jarratt D. Pytell, M.D., and colleagues wrote at the time.

Because of those limitations or confusion around them, some patients endure “cycles of complications, admission, discharge, repeated complications and readmission with little gain to their health,” Pytell’s noted in his JAMA Internal Medicine recommendations. “For many patients with OUD, effective treatment with methadone may be one of the most important therapies that a hospital or skilled nursing facility can provide.”