nursing homes

Nursing homes routinely refuse people on addiction treatment

nursing homes

Nursing facilities are not allowing patients in due to medications they have been prescribed.

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Nursing facilities routinely turn away patients seeking post-hospital care if they are taking medicine to treat opioid addiction, a practice that legal experts say violates the Americans with Disabilities Act.

After discharge from the hospital, many patients require further nursing care, whether for a short course of intravenous antibiotics, or for a longer stay, such as to rehabilitate after a stroke. But STAT has found that many nursing facilities around the country refuse to accept such patients, often because of stigma, gaps in staff training, and the widespread misconception that abstinence is superior to medications for treating addiction.

In Ohio — where 100 people a week died of opioid overdoses between August 2016 and August 2017 — a trade group representing more than 900 care facilities said in a written statement that none of its member facilities accepts patients who receive methadone or buprenorphine for addiction.

In Massachusetts, another state that is reeling from a flood of opioids, a nurse case manager at Boston Medical Center said it can be “next to impossible” to find a place that will accept a patient who takes these medications.

“It’s so bad — you’re just begging and pleading with these places,” said Maureen Ferrari, a nurse case manager who for nearly a decade has worked at Boston Medical Center finding post-hospital placement for patients. She said only two nursing facilities in the Boston area accept people on addiction medicines, adding that this roadblock can harm patients and turn a two-day hospital stay into one that is a week long, driving up health care costs.

Experts say it is illegal under the ADA for a nursing facility to refuse admission simply because a patient is prescribed addiction medicines.

“It’s well-settled in the case law that people with opioid use disorder have a disability as recognized under the ADA,” said Sally Friedman, legal director of Legal Action Center, a nonprofit policy and law group based in New York City.

“Opioid addiction is a chronic disease like any other, and nursing homes should be ashamed of themselves for excluding people who are receiving the most effective form of treatment for this chronic disease,” Friedman said.

Yet the law has not been enforced when it comes to people addicted to opioids, experts say, and many nursing facilities and industry leaders seem unaware of their obligations.

“The imperative to provide people with addiction with medication has not percolated,” said Leo Beletsky, an associate professor of law and health sciences at Northeastern University.

The Ohio Health Care Association did not respond when asked whether it knew its member facilities’ refusal to accept such patients violated the ADA. And the American Health Care Association, a group representing 13,500 long-term and post-acute care providers nationwide, also did not respond to requests for comment.

Officials with a handful of state long-term care organizations polled by STAT, including trade groups in Wyoming and Montana, said they did not know whether facilities in their area had policies on how to continue addiction treatment among patients admitted to their facility, something experts said is unsurprising.

“There is a lot of confusion about what is legal and not legal,” said Dr. Sarah Wakeman, an addiction specialist at Massachusetts General Hospital, who added that her team faces difficulty finding post-hospitalization placement “every single day” for people who take medicine for addiction.

“There are facilities that do not understand that they are not allowed to do this,” she said.

In an effort to combat this confusion, the Massachusetts Department of Public Health in 2016 issued guidance for nursing facilities caring for patients who take medicines for addiction. The state’s circular letter asserted that care facilities must provide medication-assisted treatment for people who are already on it, and who otherwise are eligible for admission. A spokesperson said that the department addresses any concerns related to the topic that are brought to its attention, and that it reviews a facility’s policies and procedures when conducting a nursing home on-site visit. But the agency has not tracked complaints about addiction-related admission denials.

 The U.S. Department of Justice has begun an investigation of detention centers that don’t make medication-assisted treatment available to inmates with addictions. And Beletsky, citing federal government sources, said a campaign to boost ADA enforcement among care facilities may be on the horizon.

It’s a move that can’t come too soon, he said. Failing to enforce the ADA for people with opioid use disorder “is a missed public health opportunity that is probably measured in lives,” Beletsky said. The Department of Justice declined to comment.

Refusing care to people on medication for addiction can have dire consequences because pressure to stop these proven treatments could open the door to relapse and overdose.

Part of the reticence to accept patients with addiction stems from unfamiliarity with the medicines used to treat them. Nursing facilities may not have a clinician licensed to prescribe buprenorphine on staff, for example, and facilities may be unaware that the patient’s primary care doctor often can continue to provide the medicine.

“We have faced hurdles even when clinicians who are discharging patients stable on medications to treat opioid use disorder are willing to continue prescribing these medications while patients are recovering at facilities,” Dr. Sabrina Assoumou, an infectious disease physician at Boston Medical Center, wrote in an email.

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