Experts offer tips for tackling substance use

Goal: Prevent hospitalization

Hospital systems and care transition teams should take a close look at their practices regarding patients for substance use problems with a goal of improving screening and discharge planning to prevent readmission of these patients, experts say.

"This group requires substantial attention; they re-utilize at high rates," says Alexander Walley, MD, MSc, assistant professor of medicine at the Boston University School of Medicine.

Hospitals could include questions about substance use in any general hospital admission or high risk patient’s screening.

"Most places do a high-risk screen on admission to see if the patient requires further psychosocial intervention, and substance use is just one more thing they could put on the screen," says Tom Sedgwick, LCSW, CCM, director of social work at New York University Langone Medical Center in New York City.

Also, hospitals that have targeted quality improvement programs, such as Project RED – Re-Engineered Discharge program, could include interventions for substance use. Programs like Project RED have demonstrated success in lowering hospital readmissions, lowering emergency room use, and lowering costs, says Brian Jack, MD, professor and vice chair in the department of family medicine at Boston University School of Medicine/Boston Medical Center in Boston. Jack is the principal investigator for Project RED.

"There are now important policy implications for hospitals," Jack adds. "They will need to meet certain quality benchmarks in order to receive payments on an incentive program from insurers and others."

Since programs like Project RED are expensive, hospitals look for ways to focus and target them to specific patient populations that will benefit most, he notes.

"There is a lot of interest in developing risk models using administrative and clinical data that will accurately predict who is likely to come back for the purpose of identifying and targeting those individuals," Jack says.

As hospitals develop and use risk assessment tools, they should keep in mind recent research findings that substance use, like depression and low health literacy, is an important and independent factor associated with rehospitalizations.

"Project RED wasn’t targeted at substance users, but we think substance users would benefit from Project RED just as non-substance users would," Walley says.

Walley and Jack were among the researchers who found that rehospitalizations are more common among patients with substance use disorders than among patients who did not have that diagnosis.

"If you discharged 100 substance users, there would be 63 utilizations at 60 days," Walley says. "Discharge 100 non-substance users and you have only 32 utilizations at 60 days."

Hospitals should follow best practice measures and look for trends in patient readmissions, suggests Mirean Coleman, MSW, LICSW, CT, senior practice associate with the National Association of Social Workers in Washington, DC.

"When patients are readmitted for the same type of problem, it’s important to assess what is really going on here," Coleman says. "Screening tools could be administered to patients admitted through the emergency room to the hospital, and that would be one way to find out if there’s a need."

Substance use screening for trauma admissions are routine at some hospitals, says Steven M. Vincent, PhD, LP, Care Center director, behavioral health services at St. Cloud Hospital of St. Cloud, MN. The hospital is part of the CentraCare Health System.

"Our functional health assessment that is done at intake involves asking a few questions about substance use, but it doesn’t really go into depth unless there’s something in the patient’s history or current presentation or trauma indications that triggers us to do a more complete assessment throughout the general hospital," Vincent says.

Vincent and the other experts provide these strategies for incorporating substance use assessment and interventions in the hospital discharge process:

Screen patients for substance use problems. Screening tools could be administered to patients who are admitted through the emergency department or are in general hospital populations. Social workers who have a certified clinical alcohol, tobacco and other drugs credential are well trained to identify this problem, Coleman says.

"The social worker can administer the screening tool and provide initial counseling regarding substance use during the hospital admission," Coleman says.

A depression screening probably should be automatic, and the patient also could be asked about alcohol use at that time, Coleman says.

Screening also could include looking at previous medical records to see if there are any patterns, Sedgwick notes.

"It’s almost intuitive when you’ve been doing it a while," Sedgwick says. "You know the signs when you see them. If someone keeps coming back because they are falling or if an older person has a changed mental status and frequent falls, then these are things we have to consider as possibly related to alcohol use."

Arrange for a case management consultation. A known substance use history might result in a case management consultation.

"A case manager can talk with the patient and sometimes the family when there’s a substance use concern that the patient doesn’t acknowledge, but the family is willing to discuss," Vincent says. "Out of that discussion, a determination is made whether we need to put the patient on an observation protocol to see if there are withdrawal signs during hospitalization."

Then, based on the case manager’s assessment, the hospital’s team will determine whether there should be a full chemical dependency evaluation, he adds.

This assessment also can guide referrals and patient education, such as providing overdose counseling and referring patients to chemical dependency treatment, as needed. (See story on substance use referrals, below.)

"If that’s done, then that will produce recommendations about what level of treatment, if any, is needed," Vincent says. "It’s included in the patient’s medical record and is included in discharge findings."

Educate patients and their families: At the very minimum, discharge teams can educate patients and their families about risk factors for substance use disorders, Vincent says.

Discharge teams also can provide follow-up interventions, Sedgwick says.

"After discharge, we make phone calls to all of our patients within 48 hours," Sedgwick says. "We check on the patient at home and see if there are any problems."

Nurses making these calls discuss the discharge plan with patients and check on any potential problems, including substance use issues. When a problem is identified, they make a referral or recommendation with the goal of reducing the patient’s risk of rehospitalization, he adds.