Creating a successful discharge plan for patients with opioid abuse issues is a huge challenge for a case manager in the cardiac care unit at Massachusetts General Hospital.

• Even young drug users can develop cardiac problems and other comorbidities in addition to addiction issues, making it difficult to find a post-acute provider.

• At Massachusetts General, multidisciplinary Addiction Consult Teams (ACTs), which include nurses, social workers, physicians, and psychiatrists, treat and follow patients with substance abuse issues.

• Sometimes it takes multiple discharge plan attempts to find one that works.

As a case manager in the cardiac medical-surgical care unit at Massachusetts General Hospital, Maria Seavey, RN, BSN, CCRN, reports that developing a workable discharge plan for patients with opioid abuse issues is one of her biggest challenges.

Seavey manages the care of opioid users whose cardiac issues are serious enough to require a stay in the cardiac ICU. Most of her patients are between 20 and 50 years old.

“Even young drug users can develop cardiac issues such as endocarditis and vascular compromise, and opioid abusers often have multiple comorbidities. This, plus their addiction, makes it complicated to develop a successful discharge plan,” Seavey says.

Opioid abuse can lead to an array of medical complications including hepatitis, HIV, cellulitis, and localized and systemic infections, in addition to overdoses and withdrawal, she adds. “It’s very costly to the healthcare system,” she says.

Her patients come from a variety of backgrounds. “Patients who are addicted to narcotics come from all walks of life. Some are down on their luck, others have mental health issues and are self-medicating, and some are chronically homeless. Many have no health insurance,” Seavey says.

At Massachusetts General, Addiction Consult Teams (ACTs) treat and follow patients with substance abuse issues. The multidisciplinary team includes addiction nurse practitioners, social workers, psychiatrists, physicians, and recovery coaches. On the cardiac service, Seavey works closely with the team to develop a workable plan.

The nurse practitioner, physician assistants, surgeons, and physicians focus on the medical aspects of the case, while the rest of the ACT concentrates on the substance abuse piece and Seavey handles the discharge.

Seavey attends rounds with the nurses and doctors and communicates closely with team members during the rest of the day. “We take advantage of all the opportunities to come up with a plan for patient care. We may stop and discuss patients when we meet in the hall, or get the team together for a family conference,” she says.

During rounds, team members talk about each patient’s condition, medical needs, and goals as well as obstacles to discharge and ways to overcome them. “We look at their living conditions, their financial needs, and community support,” she says. Some are not American citizens, or have another reason they’re unable to obtain health insurance.

Other barriers include lack of support at home, a history of homelessness, and unwillingness to change habits, Seavey says.

Seavey meets the patients as early in the stay as possible to develop rapport and trust. Most of the opioid users have extended hospital stays because of complications, and Seavey sees them every day. “By visiting them frequently and establishing a relationship, I bond with the patients on some level,” she says.

Before creating a discharge plan, case managers should be informed about all of the issues patients who abuse opioids face, Seavey says. “It often takes creativity and a lot of options to come up with a discharge plan that will work,” she says. (For details on how one patient’s discharge plan changed, see related article in this issue.)

For instance, some patients resist going to a methadone clinic because of the stigma attached, she adds. Others can’t find post-discharge treatment because they are uninsured. Some rely on suboxone to treat their opioid dependence, but need a physician to prescribe it, she says.

When patients need IV antibiotics, it is sometimes difficult to find a skilled nursing facility to take the risk, Seavey says. “They have a patient sign a contract agreeing that when a visitor comes in, the patient won’t use the IV line for drugs,” she says. “A lot of facilities also require patients to sign a contract that spells out all of the rules. If the patients don’t abide by them, they are discharged.” The state of Massachusetts offers many resources that can help people with opioid use problems, Seavey says.

Sometimes, getting a patient to agree on a discharge plan is difficult, she says. “I tell them that these are their options and they have to accept it. Sometimes, it takes several tries,” she adds.

For example, one young man with whom Seavey worked in the cardiac observation unit came into the ED from a rehabilitation facility three times in a week. He had a peripherally inserted central catheter (PICC line) and was receiving IV antibiotics, but left the rehab facility and returned an hour later in a drowsy state. Seavey talked to the patient’s insurance company, and discussed disenrollment unless he finished his treatment. The rehab facility wouldn’t take him back because he wouldn’t follow the rules. Finally, he agreed to enter a state facility to finish his IV regime.

“I don’t follow patients after they leave, so I don’t know if the plan works in the long run — but I do know that these patients are discharged from the hospital in a safe manner,” she says.