DP team needs overdose training, referral options

Brief interventions can work

Hospital discharge planning teams might increase their skills and referral options when dealing with substance use issues by giving staff overdose and counseling training. They also can improve patient care at discharge by adding more options to their referral choices for these patients, experts say.

Patients with substance use problems might be readmitted to the hospital because of accidental overdoses, so it’s important to have staff trained to counsel patients who are high-risk substance users about the risks of an overdose, says Alexander Walley, MD, MSc, assistant professor of medicine at the Boston University School of Medicine.

"These can be brief interventions done by physicians, RNs, or health promoter advocates," he explains. "The intervention lasts 15 minutes or less, and it involves having a person screened and asking the patient questions about consequences and encouraging the person to cut back or stop their substance use."

These brief interventions also can include assessing patients’ motivation to change, he adds.

"If they’re not motivated to change, you can agree to disagree," Walley says. "You can say, I understand that you feel this is not a problem for you, but as your doctor, I’m very concerned because we think this hospitalization is related to your substance use.’"

Physicians or others doing the counseling can ask patients to seek help in the future if they change their minds.

"You can say, Meantime, if you continue to drink or use drugs, please do it in the safest manner possible,’" Walley says.

"That’s where overdose training comes in: Teach them what safe drinking limits are, if it’s alcohol, and how to handle pills safely at home by keeping them locked up and taking them as prescribed," he adds.

If the counseling session results in the patient saying he wants to make a change now but doesn’t know what to do, then the physician, nurse, or case manager can ask him about what he has done in the past.

"If he says, I went to a halfway house or treatment program, but I only stayed clean for six months,’ then you say, Six months is a good amount of time, so let’s have our discharge team help you find a program similar to that,’" Walley suggests. "’So you should consider going back to that program or a similar program and have that six-month start and build on that rather than lose it.’"

The key to helping patients make the best care transition is to expand the discharge planning team’s list of potential referral options and find the one that most suits a particular patient’s situation.

For instance, there is a range of options that could begin with simple patient and family education about substance use.

"On the medical-surgical floor, the next step could be anything from initiating a physician’s statement about the need to commit the patient for chemical dependency treatment to educating the patient and family about possible alcohol misuse," 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.

Social workers can play an important role in these decisions and referrals.

"The social worker can refer the patient to appropriate referral processes in the community when the patient is [ready] for discharge," says Mirean Coleman, MSW, LICSW, CT, senior practice associate with the National Association of Social Workers in Washington, DC.

Social workers could make the referral to a substance use clinic or an outpatient facility or some private individual counseling or therapy session within the community. And there are many social workers who are certified to provide substance use counseling, too.

Discharging patients directly to a substance use rehabilitation program typically requires the patient taking the initiative, notes says Tom Sedgwick, LCSW, CCM, director of social work at New York University Langone Medical Center in New York City.

"A lot of rehab programs in New York require people to take themselves there and show that investment in treatment," he explains.

In some cities, there are home care nursing programs that have psychiatric nurses who are trained to handle patients with substance use issues, Sedgwick says.

"There would be a special program where the nurses know they have to follow these patients more closely," he says. "They have the right kind of training to serve these patients, and they try very hard to keep the patient from coming back to the hospital."

Follow-up referrals also could include recommending the patient attends Alcoholics Anonymous meetings, Vincent says.

If the patient needs active chemical dependency treatment, then the discharge team provides information on where treatment can be accessed.

"When patients are willing, we’ll try to facilitate their discharge directly to a treatment program from our medical surgical unit as well as from our psychiatric units," Vincent says.