Bann Maralyssa, Cullen Rosie, de Boer Catrien, Hrachovec Danielle, Rozler Aidan, Blume Grant
University of Washington School of Medicine, Seattle, WA, USA.
University of Washington Evans School of Public Policy and Governance, Seattle, WA, USA.
J Gen Intern Med. 2024 Oct 14. doi: 10.1007/s11606-024-09100-2.
Patients with opioid use disorder (OUD), especially those treated with methadone, face significant challenges to placement in a skilled nursing facility (SNF). Efforts to address this via legal actions have not resulted in improved access.
To understand regulatory and non-regulatory factors that impact SNF placement of patients with OUD treated with methadone.
Observational qualitative study.
Stakeholders in the hospital-to-SNF referral process as well as those with specific expertise related to OUD.
Open-ended, semi-structured interviews.
Interviews with 15 participants identified three key themes that function together in addition to logistic and financial barriers: (1) stigma and perception of risk, (2) uncertain regulatory environment, and (3) distrust between responsible entities. Fundamentally, many SNFs do not feel they can provide necessary care related to OUD and methadone. They tend to be disinclined to care for patients with OUD and express concerns about perceived risks such as overdose, violence, or discomfort to other residents. SNFs are also very motivated to avoid regulatory citations and fines related to OUD or methadone. Since confusion and misinformation about relevant policies and procedures is common, many opt to decline these patients. Compounding these challenges, entities responsible for coordinating care demonstrate poor communication and lack of transparency with each other. Referral and declination information sent between hospitals and SNFs is often considered to be incomplete or incorrect, and many hospitals have stopped referring patients with OUD treated with methadone to SNFs altogether. Regulatory bodies are often feared by healthcare providers and administrators and interaction is avoided. Finally, legal oversight representatives report that they do not receive sufficient information to properly investigate concerns.
This study identifies the climate of stigma, uncertainty, and distrust between responsible entities that stymies improvement efforts. Creation of meaningful reform must address each of these areas.
患有阿片类药物使用障碍（OUD）的患者，尤其是接受美沙酮治疗的患者，在入住专业护理机构（SNF）时面临重大挑战。通过法律行动解决这一问题的努力并未改善其入住机会。
了解影响接受美沙酮治疗的OUD患者入住SNF的监管和非监管因素。
观察性定性研究。
医院至SNF转诊过程中的利益相关者以及与OUD相关的特定专业人员。
开放式半结构化访谈。
对15名参与者的访谈确定了除后勤和财务障碍外共同起作用的三个关键主题：（1）耻辱感和风险认知，（2）监管环境不确定，（3）责任实体之间的不信任。从根本上说，许多SNF认为他们无法提供与OUD和美沙酮相关的必要护理。他们往往不愿意照顾OUD患者，并对诸如过量用药、暴力或给其他居民带来不适等感知风险表示担忧。SNF也非常希望避免与OUD或美沙酮相关的监管处罚和罚款。由于对相关政策和程序的困惑和错误信息很常见，许多机构选择拒绝接收这些患者。使这些挑战更加复杂的是，负责协调护理的实体之间沟通不畅且缺乏透明度。医院和SNF之间发送的转诊和拒绝信息通常被认为不完整或不正确，许多医院已经完全停止将接受美沙酮治疗的OUD患者转诊至SNF。医疗保健提供者和管理人员通常害怕监管机构，避免与之互动。最后，法律监督代表报告说，他们没有收到足够的信息来妥善调查相关问题。
本研究确定了阻碍改进努力的耻辱感、不确定性和责任实体之间不信任的氛围。进行有意义的改革必须解决所有这些方面的问题。
