Planning and designing the Improving Addiction Care Team (IMPACT) for hospitalized adults with substance use disorder

Addiction is a national epidemic that represents both a pressing need and a significant burden to the healthcare system.¹ Hospitals are increasingly filled with people admitted for medical complications of substance use disorders (SUD).²People with SUD have longer lengths of stay (LOS) and high readmission rates.³ Hospitalization often does not address the root cause—the SUD. For example, many hospitals replace heart valves and deliver prolonged courses of intravenous (IV) antibiotics for endocarditis from injection drug use but do not offer addiction medicine consultation, medication for addiction treatment (MAT), or linkage to posthospital SUD treatment.^4,5

Hospitalization can provide reachable moments for initiating addiction care.⁶ Medications for opioid⁷ and alcohol use disorders⁸ can be started during hospitalization, promoting engagement in outpatient SUD care⁷ and increased uptake of MAT,^7-9 and reducing readmissions.^8,10 Yet, medications for SUD are underprescribed,^11,12 and most hospitals lack inpatient addiction medicine services and pathways to timely SUD care after discharge. Furthermore, traditional SUD treatment programs are often not equipped to manage medically complex patients or they have long waitlists.¹³ Most behavioral-physical health integration occurs in ambulatory settings. This fails to engage patients who do not access primary care. There is an urgent need for models that can improve care for hospitalized patients with SUD.

Here, we describe our experience using patient needs assessment to engage stakeholders and drive local systems change. We also describe the resulting care model, the Improving Addiction Care Team (IMPACT). Our experience provides a potentially useful example to other hospitals and communities seeking to address the national SUD epidemic.

Setting

In 2012, Oregon transformed its Medicaid system by establishing 16 regional “coordinated care organizations” (CCOs) to improve outcomes and slow healthcare spending.¹⁴ In a CCO environment, hospitals assume increased financial risk, yet reforms have focused on the outpatient setting. Therefore, executive leadership at Oregon Health & Science University (OHSU), an urban academic medical center, asked clinician-leaders to design point-of-care improvements for Medicaid-funded adults and build on existing models to improve care for socioeconomically vulnerable adults.^15,16 One priority that emerged was to make improvements for hospitalized adults with SUD. Of the adult inpatients at OHSU, 30% have Medicaid and 15% have SUD by administrative data alone. Before we started our work, OHSU lacked inpatient addiction medicine services.

Local Needs Assessment

To understand local needs and opportunities, we surveyed hospitalized adults with SUD. We used the electronic health record to generate a list of inpatients flagged by nurses for risky alcohol or drug use. A research assistant screened consecutive adults (≥18 years old) and invited those who screened positive for alcohol use (Alcohol Use Disorders Identification Test–Consumption [AUDIT-C])¹⁷ or drug use (single-item screener)¹⁸ to participate. We excluded non-English speakers, incarcerated adults, people using only marijuana or tobacco, psychiatry inpatients, and people unable to consent. Surveys assessed social and demographic factors, healthcare utilization, substance use severity, and treatment experience. Participants who reported high-risk illicit drug or alcohol use¹⁹ were asked to indicate their readiness to change on a 3-point scale developed for this study. Response range included: no interest, interest in cutting back, or interest in quitting. A subset of participants completed in-depth qualitative interviews exploring patient perceptions of substance use treatment needs.²⁰ We obtained hospital administrative data from hospital financial services.