Implementing an Opioid Risk Reduction Program in the Acute Comprehensive Inpatient Rehabilitation Setting

Outcomes after inpatient rehabilitation for older adults with hip fractures: A cross-sectional study

OBJECTIVE

To investigate the clinical characteristics of older adults undergoing inpatient rehabilitation after hip fractures and to find factors associated with discharge location.

DESIGN

Cross-sectional analysis.

SETTING

Inpatient rehabilitation units in the United States.

PARTICIPANTS

≥65 years old patients with hip fractures.

INTERVENTION

Inpatient rehabilitation with ≥1 hour of physical and occupational therapy per weekday.

MAIN MEASURES

Home versus nonhome discharges.

RESULTS

79% of 7439 (n = 5,908) patients were discharged to home after a median stay of 14 days, while 13% (n = 990) were discharged to skilled nursing facilities. 6% (n = 423) were transferred to acute care during rehabilitation stay. Functional mobility levels for bed-to-chair transfer and sit-to-stand at admission were significantly lower in patients discharged to facilities than in patients discharged to home. Older age (OR 0.97 per 1 year, CI 0.96-0.98); comorbidities of dementia (OR 0.68, CI 0.56-0.83) and cerebrovascular disease (OR 0.53, CI 0.36-0.78); and the use of opioid analgesics (OR 0.71, CI 0.56-0.91), antipsychotics (OR 0.73, CI 0.58-0.92), and anticonvulsants (OR 0.81, CI 0.67-0.96), and lower initial functional levels in bed-to-chair transfers (OR 0.08, CI 0.05-0.12) for dependent level; OR 0.16, CI 0.10-0.25 for level requiring maximal assistance; OR 0.38, CI 0.24-0.60 for level requiring partial, moderate assistance), were associated with a decreased likelihood of discharge to home after inpatient rehabilitation.

CONCLUSION

Older adults with dementia, cerebrovascular disorders, and lower bed-to-chair transfer mobility levels at admission after hip fractures may benefit from additional targeted rehabilitation to improve the chances of a successful community discharge.

An initiative to increase opioid overdose education and naloxone distribution for homeless veterans residing in contracted housing facilities

BACKGROUND

Up to 35% of veterans with opioid use disorder (OUD) are homeless, and veterans with OUD are nearly 29 times higher risk for homelessness; however, few are prescribed naloxone, an evidence-based intervention to reverse life-threatening opioid overdose.

LOCAL PROBLEM

Many housing facilities for homeless veterans contracted with the San Francisco Veterans Affairs Health Care System are located in neighborhoods with high rates of opioid overdose. No systematic interventions have been implemented to provide opioid overdose education and naloxone kits to veterans and staff at these facilities. This quality improvement (QI) initiative aimed to increase provision of opioid overdose education and naloxone for veterans and staff at contracted housing facilities.

METHODS

This was a prospective single-arm cohort QI intervention. All contracted veteran housing programs were included. Descriptive statistics evaluated results.

INTERVENTIONS

A total of 18 contracted veteran housing programs were contacted from July 2019 through January 2020 to schedule training.

RESULTS

Of those, 13 programs responded to outreach and 10 visits were completed at 8 housing facilities. Training was provided by pharmacist and nurse practitioner trainers to 26 staff members and 59 veterans. Naloxone was prescribed to 37 veterans.

CONCLUSIONS

A pharmacist-led and nurse practitioner-led initiative was effective in increasing veteran and staff access to opioid overdose education and naloxone at >44% contracted veteran housing facilities. Challenges included lack of response from housing programs, low veteran turn out, and inability to provide naloxone to veterans not enrolled/ineligible for health care. Future initiatives should examine strategies to standardize access in homeless veterans' programs.

Dispensing a Naloxone Kit at Hospital Discharge: A Retrospective QI Project

PURPOSE

The aim of this quality improvement (QI) project was to increase the coprescription of naloxone kits at patient discharge as a harm reduction strategy to combat the opioid epidemic. An interdisciplinary team identified hospitalized medical patients who were at high risk for an opioid overdose or opioid-related adverse event.

METHODS

Led by a physician champion, an interdisciplinary QI team composed of physicians (MDs and doctors of osteopathic medicine), advanced practice providers (NPs and physician assistants), RNs, care coordinators, social workers, and pharmacists developed and implemented a naloxone distribution program on one medical unit at an academic tertiary care center. The team developed and implemented criteria to identify high-risk patients, workflow for patient screening, staff and patient education programs, and processes for naloxone kit delivery to the patient's bedside. Data on naloxone kit distribution from the seven months prior to implementation (March 2018 to September 2018) and the seven months after implementation (October 2018 to April 2019) were evaluated and are reported descriptively.

RESULTS

Two patients preimplementation and 64 patients postimplementation received a naloxone kit at discharge. In the postimplementation group, common reasons for identifying a patient as at high risk for an overdose or adverse event were a prescription for a pain medication at a daily dosage greater than or equal to 50 morphine milligram equivalents (50% of patients), concomitant opioid and benzodiazepine use (19%), history of substance use disorder (11%), and medication-assisted treatment (9%). Most patients in the postimplementation group (86%) received a naloxone kit at a personal cost of $1 or less.

CONCLUSION

This unit-based pilot project was successful in identifying patients at high risk for an opioid overdose or opioid-related adverse event and in providing naloxone kits and education at hospital discharge.