The transitions team at Highland Hospital went through SBIRT training to learn how to work with substance abuse patients.
As a safety net hospital, we had a lot of patients with substance abuse problems. At first we ignored these patients because we didn’t think we could have a meaningful impact on their readmission rates. Then we realized that 60% of our patients were using. Many of our CHF and COPD patients were in their 20s-40s. Substance abuse was clearly not a side problem, but one of the main reasons our patients were being readmitted. In fact, in many cases, substance abuse disorder is the primary chronic condition underlying COPD and CHF.
The challenge was that we were truly incompetent to assess and manage patients’ substance abuse needs. We didn’t know how to broach the subject and were nervous to talk about a topic that we knew so little about.
Highland Hospital is a non-profit teaching hospital in Oakland, CA. It is a safety net setting hospital with 236 beds that serves a diverse population including low-income, uninsured, and vulnerable populations. Their transitions program began in 2012 and is influenced by Project RED and the Transitional Care Model.
What We Tried
We got together with other local hospitals that also had a large number of substance abuse patients for a forum. At the forum, we had a psychopharmacologist who trained us on SBIRT—a method for working with substance abuse patients that includes Screening, a Brief Intervention, and then Referral to Treatment. He worked with our team to help us build skills in motivational interviewing, assessment, and referrals.
Every patient now gets screened using the CAGE-AID questionnaire in their follow up phone call or home visit—and, if needed, we’ll perform a brief intervention and refer them to treatment. The intervention is very simple, usually just a few minutes, and it focuses on helping them connect their substance abuse to their illness and admission to the hospital. We’re not telling them to stop using, which they’ve already heard, we’re explaining to them how drug use is making their CHF or COPD worse.
We’re much more comfortable talking about substance abuse with our patients now. We address it head on with them. It’s really surprising how many of the patients have said, “No one ever told me this could happen. I knew it was unhealthy to do crack, but I didn’t think my heart was going to be permanently damaged so that I’d have trouble walking two blocks.” We’ve had a lot of success getting patients to accept treatment, stop using altogether, or consider cutting back use.
The SBIRT training helped with building team spirit. We all had to admit how little we knew about substance abuse and this vulnerability combined with learning together has helped to bring our team together.
We realized that the best time for the screening and brief intervention was right when the patient got home. CHF and COPD exacerbations make you feel like you’re dying and having that memory fresh in patient’s heads is helpful for the counseling. Patient cognition is also impaired in the hospital, so it’s best to wait until they’re slightly better.
It’s important to hear where patients are and recommend the right level of care. Very often treatment failure is a result of treatment at the wrong level of care. Imagine if you have a small pot problem and you get sent to a treatment program with heavy crack users. That will turn you off from future interventions.
It helped to look at substance abuse the way we look at any other medical condition. It’s the same dynamic as any other compliance situation.
We learned that a passive referral (e.g. just handing a patient a brochure about a program) was not likely to be followed up on. We do our best to do warm hand offs to treatment programs and then check in with patients to see how they feel about it.