High Medical Service Utilizers
Of considerable concern, particularly to general or acute care hospitals, are patients who are high medical service utilizers (HMSUs), particularly those admitted for withdrawal management (i.e., detoxification). Staff complain that they see these people—who they uncharitably refer to as “high fliers”—over and over again for withdrawal management with no discernable improvement. Some people have even postulated that this kind of utilization by HMSUs plays a role in increasing health care costs as well as negative consequences such as impairment of patients’ cognitive abilities (Kouimtsidis, Sharma, Charge, & Smith, 2015).
According to The ASAM Criteria (Mee-Lee et al., 2013), one of the primary goals for withdrawal management is the completion of detoxification and timely entry into continued treatment. However, in other than organized withdrawal management programs, staff sometimes view their responsibilities as simply providing the actual withdrawal management services without emphasis on the timely entry into continued treatment. Said another way, staff view the detoxification as a discrete event rather than as an initial step in a disease management process.
Given that addiction is a chronic, relapsing brain disease, this would be analogous to stabilizing diabetics who have been hospitalized for insulin shock or diabetic ketoacidosis, then discharging them without a follow-up plan for managing the disease, or stabilizing people with bipolar disorder in a hospital after a manic event without a plan to control their mood fluctuations after discharge. In these examples, the diseases are treated as if they are acute disorders (i.e., the episode that precipitated the admission) rather than chronic conditions. This misguided approach is seen clearly in Medicare, which pays only for acute stabilization of psychiatric problems or detoxification for substance use disorders (SUDs) in an inpatient hospital, although it will reimburse for cardiac rehabilitation after an adverse cardiac event.
If the role of nursing staff is viewed as traditional nursing, the problem of SUD-related HMSUs will continue. The first part of the intervention to reduce the readmissions is an ASAM dimensional assessment (Mee-Lee et al., 2013). In this assessment we can conclude that ASAM Dimension 1 (acute intoxication, withdrawal potential) will have been resolved by the hospital’s withdrawal management procedures. Problems in Dimension 2 (biomedical conditions and complications) will also have been identified. Acute Dimension 2 problems (e.g., a wound that needs cleaning and debridement) can be resolved during the hospitalization. Dimension 2 chronic problems (e.g., diabetes or hypertension) may be addressed with a care plan that includes appropriate medications and referral for follow-up treatment.
The problem becomes more complex with the assessment of ASAM Dimensions 3 through 6. In contrast to a “detoxification unit,” nursing staff are generally not trained to do such assessments, might view them as outside their normal scope of practice, and may be resistant because of the additional workload. When a hospital does not have an organized withdrawal management service and patients are assigned to services where there are available beds, it is called “scatter bed placement.”
Furthermore, in general hospital nurses may be assigned to services as needed based on census. Therefore, an addiction-trained nurse may be transferred away from detoxing patients to some other medical, surgical, or orthopedic service to meet staffing needs. Or, conversely, nurses without addiction training may be transferred into general medical and surgical services where there are patients undergoing detoxification. In addition to the need for training in assessment, these nurses would have to make referrals to respond to the assessment data, which would require them to have extensive knowledge of resources in the community. A finding of homelessness in Dimension 6 would require assessors to be aware of services in the community that could remedy that situation. All in all, the burden on nursing staff seems to be untenable.
Obviously, ASAM Dimension 5 (relapse, continued use, continued problem potential) is the key to interrupting this revolving door and there are two nonexclusive approaches to achieve that end. The first is induction of antiaddiction drugs and evidence-based practices. Oral naltrexone and its injectable, extended release form Vivitrol can be used for alcohol and opioid dependence, but opioid dependence requires seven to fourteen days of abstinence after last use in order not to precipitate withdrawal. Patients can be inducted on buprenorphine combined with naloxone/Suboxone while still hospitalized. In terms of costs, most commercial insurance companies will pay for the medications and Alkermes, the company that produces Vivitrol, will pay for up to $500 per month in copay assistance. In most states Medicaid will pay for either Vivitrol or Suboxone. Inductions must be followed by referrals to providers who can continue the medication once patients have returned to their home areas. This can be accomplished by referral of patients to covered physicians by the nursing staff.
The second option is to hire individuals—social workers, alcohol and drug counselors, and others—with addiction qualifications who could travel throughout hospitals to wherever the detoxing patients are, do the assessments, and make appropriate referrals for continued treatment and acquisition of any necessary nonclinical services such as housing. This second solution would incur additional staff costs.
There are two considerations here. One is whether additional expenses would be offset by a reduction in the repetitive admission of patients who have poor or no form of health care reimbursement, which is still a cost to the hospitals providing their care. The other issue is to assure that cost considerations do not negatively impact the provision of quality care. c
About the Author
Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.
Kouimtsidis, C., Sharma, E., Charge, K. J., & Smith, A. (2015). Structured intervention to prepare dependent drinkers to achieve abstinence: Results from a cohort evaluation for six months postdetoxification. Journal of Substance Use, 21(3), 331–4.
Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D., Miller, M. M., & Provence, S. M. (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions. Carson City, NV: The Change Companies.