Clinician Perspectives on Addiction Medicine Consultation Service in Inpatient Settings

 
11/02/2023
 
“This is one of the most complex
medical problems that we treat in
the hospital”: Hospital clinician
perspectives on an inpatient
addiction medicine consultation
service
 
Madison Rodríguez; Naomi López-Solano; Hannah Snyder, MD;
Marlene Martín, MD; Oanh Kieu Nguyen, MD, MAS
 
2
 
Background
 
 
1 of 9 hospitalized patients has a
substance use disorder (SUD
).These
patients face many inequities due to
stigma and lack of addiction knowledge
among healthcare workers.
 
Addiction consultation teams (ACT) have
arisen 
to
 support 
hospitalized patients
and healthcare 
members provide
evidence-based care
 
In 2019, our urban, academic, safety-net
hospital launched an interprofessional
ACT
 
ACT Evaluation - AMERSA
 
ACT Evaluation - AMERSA
 
3
 
Study Questions
 
 
1.
What are 
clinicians’ perspectives on SUD care
gaps prior to ACT
?
 
2.
What care gaps did ACT address?
 
3.
 What care gaps remain 
with ACT in place?
 
4
 
Methods
 
 
 
ACT Evaluation - AMERSA
 
Results: Participant Characteristics (n=33)
 
ACT Evaluation - AMERSA
 
 
a
 Includes internal medicine (n=9), family and community medicine (n=4), cardiology (n=1)
b
 Includes
 trauma/general surgery (n=6), orthopedic surgery (n=4), neurosurgery (n=2)
 
Results
 
ACT Evaluation - AMERSA
 
Results
 
ACT Evaluation - AMERSA
 
“I’m [comfortable] managing withdrawal symptoms
with the other stuff, like Klonopin, Loperamide, etc.
isn’t an issue, but it’s just [I have] this discomfort
[and] lack of experience around titrating treatment for
opioid use disorder. Methadone, buprenorphine, etc.”
      
   
– Participant 329
 
ACT Evaluation - AMERSA
 
Lack of formal SUD treatment
training 
before
 ACT
 
“The handoff on leaving the hospital was a bit [tricky] because for
the most part neither we nor our social work colleagues were
necessarily that familiar with the different types of treatment
programs available in the outpatient setting. So, it was often just
like a handoff back to primary care who we hoped would link the
patient to outpatient [SUD care] good enough.”
       
Participant 321
 
ACT Evaluation - AMERSA
 
Lack of outpatient care linkage 
before
ACT
 
“[Before ACT, SUD care was] ...like phone-a-friend. Because as I
said, this has never been my expertise….
 
We used to do weird
things. I feel like we used to consult the pain service…[because
there’s] this idea of, well, they probably have more understanding
of interactions between different narcotics… [and] they were kind
of always like, “What’s your specific pain question?”
 
– Participant 330
 
ACT Evaluation - AMERSA
 
Patchwork of Resources 
before
 ACT
 
Results
 
ACT Evaluation - AMERSA
 
“The immense amount of compassion that I now have
[for patients with SUDs] has been transformative…[in
terms of meeting] them where they are and [being]
able to give them high quality care without that stigma
or judgement…”
       
– Participant 332
 
ACT Evaluation - AMERSA
 
ACT helped reduce SUD-related
stigma
 
“I think the most helpful thing is that they [ACT]
actually talk to the patient.  I think that it helps for
patients to be heard… ACT does a good job of
listening to the patients. And I think that helps overall…
I just can’t listen to them to the extent that ACT can...”
        
– Participant 317
 
ACT Evaluation - AMERSA
 
ACT helped establish rapport with
patients
 
“[The most helpful thing about ACT is] that I can call an expert…and
I have enough humility to know that I am not an expert in addiction
medicine and that I am probably not asking the right questions or
thinking about all of the multiple facets of it. […] I think ACT] has
allowed me to feel like I am providing better care for the patient…”
         
– Participant 316
 
ACT Evaluation - AMERSA
 
ACT helped improve inpatient care
 
Results
 
ACT Evaluation - AMERSA
 
The schools prioritize things like heart failure and diabetes and
cancer. Don’t really prioritize cocaine use, homelessness, and
structural racism. They may speak about them in academic terms,
but they don't actually teach people the skills to try to address
people at the front line, “How do I help this person in front of me
whose life is being affected very deeply by this issue?”
 
         
- Participant 311
 
 
ACT Evaluation - AMERSA
 
SUD not treated with the same
priority as other medical conditions
 
Presentation Title
 
17
 
“I think this is one of the most complex medical problems that
we treat in the hospital… it takes continuity. So, I feel like the
inpatient management is just the tip of the iceberg, and then,
the outpatient management is what really matters and being
able to provide patients with the resources and coordination
to continue cessation.”
        
- 
Participant 309
 
 
 
Gaps in care transitions
 
Summary of Findings
 
 
ACT
 meaningfully addresses knowledge and care 
gaps for hospital
clinicians and patients with SUD within hospital walls
Many gaps remain around streamlining outpatient-
to-inpatient and inpatient-
to-outpatient 
care transitions and specialty-specific co-management
 
ACT Evaluation - AMERSA
 
Implications
 
 
Inpatient addiction medicine consultation services should be considered an
essential medical subspecialty consultation service at all hospitals
Increased attention to SUD-related care transitions is needed to maximize
the potential impact of hospital-initiated SUD treatment after leaving the
hospital
We did not address challenges with financing this model of care, which is a
major threat to sustainability
 
ACT Evaluation - AMERSA
 
Questions and Discussion
 
 
 
Contact us:
Madison.Rodriguez@ucsf.edu
Oanh.Nguyen@ucsf.edu
Marlene.Martin@ucsf.edu
 
T
hanks to
ACT patients and members
California Health Care Foundation
 
ACT Evaluation - AMERSA
 
References
 
 
1.
Alcohol-related deaths, which increased during the first year of the COVID-19 pandemic, continued to rise in
2021. National Institute on Alcohol Abuse and Alcoholism. (
https://www.niaaa.nih.gov/news-events/research-
update/alcohol-related-deaths-which-increased-during-first-year-covid-19-pandemic-continued-rise-2021
).
2.
Drug Overdose Death Rates. National Institute on Drug Abuse; 2023.
3.
Suen LW, Makam AN, Snyder HR, et al. National Prevalence of Alcohol and Other Substance Use Disorders
Among Emergency Department Visits and Hospitalizations: NHAMCS 2014-2018. J Gen Intern Med
2022;37(10):2420-2428. (In eng). DOI: 10.1007/s11606-021-07069-w.
4.
Englander H, Jones A, Krawczyk N, et al. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping
Review and Key Informant Interviews. Journal of General Internal Medicine 2022;37(11):2821-2833. DOI:
10.1007/s11606-022-07618-x.
 
 
ACT Evaluation - AMERSA
 
22
 
Methods
 
 
O
ne-on-one semi-structured interviews with hospital-based clinicians in an
urban safety-net hospital and level 1 trauma center in San Francisco,
California 1 
year 
after full 
A
CT implementation
We aggregated codes using a mixed deductive and inductive analytic
approach into broader themes identifying significant patterns and capturing
key findings related to our evaluation questions
 
ACT Evaluation - AMERSA
Slide Note

Hello, my name is Madison Rodriguez, and I am a researcher at University of California, San Francisco. I’d like to acknowledge my co-authors listed here.

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Hospital clinicians share their perspectives on gaps in substance use disorder (SUD) care before and after the implementation of an Addiction Consultation Team (ACT) in an urban hospital. The study reveals the impact of ACT on addressing SUD care gaps, reducing stigma, improving patient rapport, and enhancing medical management, while also highlighting ongoing challenges and areas for improvement.


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  1. This is one of the most complex medical problems that we treat in the hospital : Hospital clinician perspectives on an inpatient addiction medicine consultation service Madison Rodr guez; Naomi L pez-Solano; Hannah Snyder, MD; Marlene Mart n, MD; Oanh Kieu Nguyen, MD, MAS 11/02/2023

  2. Background 1 of 9 hospitalized patients has a substance use disorder (SUD).These patients face many inequities due to stigma and lack of addiction knowledge among healthcare workers. Addiction consultation teams (ACT) have arisen to support hospitalized patients and healthcare members provide evidence-based care In 2019, our urban, academic, safety-net hospital launched an interprofessional ACT ACT Evaluation - AMERSA 2

  3. Study Questions 1. What are clinicians perspectives on SUD care gaps prior to ACT? 2. What care gaps did ACT address? 3. What care gaps remain with ACT in place? ACT Evaluation - AMERSA 3

  4. Methods Design Qualitative Population Setting Hospital-based clinicians Urban safety-net hospital and level 1 trauma center in San Francisco, California 1 year after ACT implementation 1-on-1 semi-structured interviews Aggregated codes using a mixed deductive and inductive analytic approach until thematic saturation Measures Analytic Approach ACT Evaluation - AMERSA 4

  5. Results: Participant Characteristics (n=33) Characteristic Clinical role Physician Nurse Practitioner Years in practice, median (IQR) Subspecialty Medical specialtya Surgical specialtyb Obstetrics and gynecology Participants, n (%) 26 (79) 7 (21) 14 (10-21) 14 (42) 12 (36) 7 (21) a Includes internal medicine (n=9), family and community medicine (n=4), cardiology (n=1) b Includes trauma/general surgery (n=6), orthopedic surgery (n=4), neurosurgery (n=2) ACT Evaluation - AMERSA

  6. Results Domain Themes SUD care gaps before ACT Lack of formal SUD treatment training Lack of outpatient care linkage Utilization of informal, patchwork resources Helped reduce SUD-related stigma Helped establish rapport with patients Improve medical management Established a formal mechanism for SUD treatment Ongoing challenges SUD-related stigma Specialty-specific gaps in post-discharge care Difficulty obtaining needed information for continuity of in-hospital SUD treatment Gaps filled by ACT ACT Evaluation - AMERSA

  7. Results Domain Themes SUD care gaps before ACT Lack of formal SUD treatment training Lack of outpatient care linkage Utilization of informal, patchwork resources Helped reduce SUD-related stigma Helped establish rapport with patients Improve medical management Established a formal mechanism for SUD treatment Ongoing challenges SUD-related stigma Specialty-specific gaps in post-discharge care Difficulty obtaining needed information for continuity of in-hospital SUD treatment Gaps filled by ACT ACT Evaluation - AMERSA

  8. Lack of formal SUD treatment training before ACT I m [comfortable] managing withdrawal symptoms with the other stuff, like Klonopin, Loperamide, etc. isn t an issue, but it s just [I have] this discomfort [and] lack of experience around titrating treatment for opioid use disorder. Methadone, buprenorphine, etc. Participant 329 ACT Evaluation - AMERSA

  9. Lack of outpatient care linkage before ACT The handoff on leaving the hospital was a bit [tricky] because for the most part neither we nor our social work colleagues were necessarily that familiar with the different types of treatment programs available in the outpatient setting. So, it was often just like a handoff back to primary care who we hoped would link the patient to outpatient [SUD care] good enough. Participant 321 ACT Evaluation - AMERSA

  10. [Before ACT, SUD care was] ...like phone-a-friend. Because as I said, this has never been my expertise . We used to do weird things. I feel like we used to consult the pain service [because there s] this idea of, well, they probably have more understanding of interactions between different narcotics [and] they were kind of always like, What s your specific pain question? Patchwork of Resources before ACT Participant 330 ACT Evaluation - AMERSA

  11. Results Domain Themes SUD care gaps before ACT Lack of formal SUD treatment training Lack of outpatient care linkage Utilization of informal, patchwork resources Helped reduce SUD-related stigma Helped establish rapport with patients Improve medical management Established a formal mechanism for SUD treatment SUD-related stigma Specialty-specific gaps in post-discharge care Difficulty obtaining needed information for continuity of in-hospital SUD treatment Gaps filled by ACT Ongoing challenges ACT Evaluation - AMERSA

  12. ACT helped reduce SUD-related stigma The immense amount of compassion that I now have [for patients with SUDs] has been transformative [in terms of meeting] them where they are and [being] able to give them high quality care without that stigma or judgement Participant 332 ACT Evaluation - AMERSA

  13. ACT helped establish rapport with patients I think the most helpful thing is that they [ACT] actually talk to the patient. I think that it helps for patients to be heard ACT does a good job of listening to the patients. And I think that helps overall I just can t listen to them to the extent that ACT can... Participant 317 ACT Evaluation - AMERSA

  14. [The most helpful thing about ACT is] that I can call an expert and I have enough humility to know that I am not an expert in addiction medicine and that I am probably not asking the right questions or thinking about all of the multiple facets of it. [ ] I think ACT] has allowed me to feel like I am providing better care for the patient ACT helped improve inpatient care Participant 316 ACT Evaluation - AMERSA

  15. Results Domain Themes SUD care gaps before ACT Lack of formal SUD treatment training Lack of outpatient care linkage Utilization of informal, patchwork resources Helped reduce SUD-related stigma Helped establish rapport with patients Improve medical management Established a formal mechanism for SUD treatment Ongoing challenges SUD-related stigma Specialty-specific gaps in post-discharge care Difficulty obtaining needed information for continuity of in-hospital SUD treatment Gaps filled by ACT ACT Evaluation - AMERSA

  16. The schools prioritize things like heart failure and diabetes and cancer. Don t really prioritize cocaine use, homelessness, and structural racism. They may speak about them in academic terms, but they don't actually teach people the skills to try to address people at the front line, How do I help this person in front of me whose life is being affected very deeply by this issue? SUD not treated with the same priority as other medical conditions - Participant 311 ACT Evaluation - AMERSA

  17. I think this is one of the most complex medical problems that we treat in the hospital it takes continuity. So, I feel like the inpatient management is just the tip of the iceberg, and then, the outpatient management is what really matters and being able to provide patients with the resources and coordination to continue cessation. Gaps in care transitions - Participant 309 Presentation Title 17

  18. Summary of Findings ACT meaningfully addresses knowledge and care gaps for hospital clinicians and patients with SUD within hospital walls Many gaps remain around streamlining outpatient-to-inpatient and inpatient- to-outpatient care transitions and specialty-specific co-management ACT Evaluation - AMERSA

  19. Implications Inpatient addiction medicine consultation services should be considered an essential medical subspecialty consultation service at all hospitals Increased attention to SUD-related care transitions is needed to maximize the potential impact of hospital-initiated SUD treatment after leaving the hospital We did not address challenges with financing this model of care, which is a major threat to sustainability ACT Evaluation - AMERSA

  20. Questions and Discussion Contact us: Madison.Rodriguez@ucsf.edu Oanh.Nguyen@ucsf.edu Marlene.Martin@ucsf.edu Thanks to ACT patients and members California Health Care Foundation ACT Evaluation - AMERSA

  21. References 1. Alcohol-related deaths, which increased during the first year of the COVID-19 pandemic, continued to rise in 2021. National Institute on Alcohol Abuse and Alcoholism. (https://www.niaaa.nih.gov/news-events/research- update/alcohol-related-deaths-which-increased-during-first-year-covid-19-pandemic-continued-rise-2021). 2. Drug Overdose Death Rates. National Institute on Drug Abuse; 2023. 3. Suen LW, Makam AN, Snyder HR, et al. National Prevalence of Alcohol and Other Substance Use Disorders Among Emergency Department Visits and Hospitalizations: NHAMCS 2014-2018. J Gen Intern Med 2022;37(10):2420-2428. (In eng). DOI: 10.1007/s11606-021-07069-w. 4. Englander H, Jones A, Krawczyk N, et al. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. Journal of General Internal Medicine 2022;37(11):2821-2833. DOI: 10.1007/s11606-022-07618-x. ACT Evaluation - AMERSA

  22. Methods One-on-one semi-structured interviews with hospital-based clinicians in an urban safety-net hospital and level 1 trauma center in San Francisco, California 1 year after full ACT implementation We aggregated codes using a mixed deductive and inductive analytic approach into broader themes identifying significant patterns and capturing key findings related to our evaluation questions ACT Evaluation - AMERSA 22

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