Quality Oversight

Trustees Play Major Role in Addressing Substance Use Crisis

Board oversight of quality improvement and patient safety has been shown to correlate with improved patient outcomes

By Richard Bottner, Karla Hardesty, Korrey Klein and Benjamin Anderson

Across the United States the number of deaths and medical complications from unhealthy substance use continue to skyrocket. Behind the alarming numbers of people impacted are individuals: fathers and mothers, sons and daughters, brothers and sisters and dear friends. Despite significant national attention, the substance use epidemic continues to impact every neighborhood in the country. Rural and urban communities alike continue to struggle with improving care and outcomes for people with substance use disorders and addiction. As the nation continues to identify and implement public health programs to curb this national health crisis, hospitals and health systems have a unique role to play.

According to the Centers for Disease Control and Prevention (CDC), substance use disorders (SUD) are “treatable, chronic diseases characterized by a problematic pattern of use of a substance or substances leading to impairments in health, social function, and control over substance use.” While opioids have received much of the national attention around unhealthy substance use, alcohol, stimulants, tobacco and increasing use of cannabis also represent significant public health concerns. The burden of illness across the nation related to these substances is massive — over 40 million people in the U.S. have a substance use disorder, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Specific to illicit substances, more than 107,000 people died of a drug overdose in the U.S. in 2021, the highest number ever recorded and a 15% increase from 2020, as determined by the National Center for Health Statistics.

This article describes the important role hospitals and their boards can play in supporting the SUD care continuum and improving addiction care in hospitals and health systems and the communities they serve.

Impact of Substance Use Disorders on Hospitals

A recent analysis by Premier based on input from over 4,000 hospitals nationwide found that opioid use disorder alone costs hospitals $95 billion per year, nearly 8% of all hospital expenditures. Between 1998 and 2016, there were over 5.5 million hospitalizations across the U.S., primarily for alcohol use disorder. Nationally, approximately one in 11 visits to the emergency department and one in nine hospitalizations are related to substance use disorder, accounting for up to 33% of all admissions in safety net settings. Contrary to common belief, many hospitalizations are unrelated to overdose or withdrawal specifically. Reasons for hospital admission include infections of the heart, skin or joints which often result in lengthy, complex and expensive hospitalizations.

Patients with SUD may be cautious to engage in medical care because of negative past experiences with the health care system. In fact, up to 30% of patients with SUD self-discharge or leave the hospital “against medical advice” because of stigma, inadequate control of cravings or fear of mistreatment. Patients with SUD are also more likely to be readmitted within 30 days of hospital discharge. These are preventable readmissions. Moreover, when patients are not provided access to resources and pathways to treatment during an acute hospitalization, 80% of patients will return to substance use.

It is critical to appreciate that hospitalization is a reachable moment for patients who may not be engaged in care otherwise. Hospitalization is the ideal time to “meet patients where they are” and provide supportive resources related to SUD. Patients who initiate SUD care during hospitalization are more likely to enter outpatient treatment, stay in treatment longer and have more substance-free days compared to those offered only a referral. Patients with SUD who are linked to outpatient SUD programs post-discharge are also less likely to be readmitted at 30 and 90 days for SUD-related reasons.

What Hospital Boards Can Do

The Institute for Healthcare Improvement promotes a high degree of board engagement in quality improvement and patient safety activity. In fact, board oversight of quality improvement and patient safety has been shown to correlate with higher performance on key quality indicators and improved patient outcomes. According to GovernWell, boards have the responsibility to take four leadership actions, which have been applied to substance use disorders below.

1. Establish Strategic Intent. Boards can ensure that mission, values and strategic priorities reflect commitment to improving care and outcomes for patients with substance use disorders.

2. Lead through Collaboration. Boards can promote the importance of building community engagement and connections between hospitals and community-based organizations that serve people with substance use disorders. Engaging the vast community networks of trustees can support and solidify this approach.

3. Reflect, Understand and Learn. Boards can incorporate and lean on people with lived experience, including past patients of the hospital, to better illuminate opportunities for care improvement. As is the case for all quality improvement and patient safety, a “culture of caring” should be established to promote engagement among providers and staff and encourage disclosure of opportunities to better serve people with substance use disorders.

4. Ensure Meaningful, Measurable Goals. Measurement is key to ensuring ongoing clinical and systems improvement for people with substance use disorder. Numerous measures related to the substance use disorder care continuum are available from the American Hospital Association’s (AHA) “Stem the Tide” program, American Society for Addiction Medicine, National Quality Forum and the Centers for Medicare & Medicaid Services, among others.

Boards can also look to partner with various local, state and national affiliations for participation in advocacy efforts to address substance use disorders. Boards can promote evidence-based practice through their quality programs, advocate for SUD-related education, and perhaps most importantly, serve as a vital conduit between the hospital’s SUD work and the community. Public health messaging is a core function of governance. Boards bring their diverse community perspective to hospitals and are also responsible for communicating hospitals’ priorities and programs to the community, including work around mental health and addiction. SAMHSA and AHA have toolkits and resources for board members to learn more about SUD, various community models and advocacy.

What Hospitals Can Do

Hospitals are critical access points along the SUD care continuum, and therefore, must be well equipped to address key areas. Prevention, treatment, harm reduction and recovery are the generally accepted and nationally recognized areas of focus in the SUD care continuum.

Prevention strategies are used to mitigate individuals away from developing a substance use disorder. The most notable prevention strategy in recent history has been the focus on safe and appropriate prescribing of opioids. Prevention is important but insufficient by itself. This is clearly exemplified in recognizing that while we are prescribing far less opioids as a medical community, the number of overdose deaths continues to skyrocket.

Treatment is a critical and vastly underutilized part of the care continuum. The treatment system in the U.S. includes prescribing medications such as buprenorphine and methadone for opioid use disorder, naltrexone for alcohol use disorder, and nicotine replacement therapy for tobacco use disorder — to name a few. Medications are often coupled with behavioral change support, which can include cognitive behavioral therapy and sometimes residential or partial hospitalization programs.

Harm reduction preserves patient autonomy and promotes appreciation that recovery is a patient-centered journey that does not necessitate total abstinence. As defined by SAMHSA, harm reduction is “an approach that emphasizes engaging directly with people who use drugs to prevent overdose and infectious disease transmission, improve the physical, mental, and social wellbeing of those served, and offer low-threshold options for accessing substance use disorder treatment and other health care services.”

Recovery includes four critical dimensions for patients including: achieving good health, establishing a stable place to live, developing meaning and purpose, and integrating into a community complete with support structures.

There are many opportunities for hospitals to integrate prevention, treatment, harm reduction and recovery strategies (see “Caring for People with Substance Use Disorders: Hospital-Based Interventions” below). Such interventions must consider the unique operating environments and practice settings within the walls of each hospital, primarily emergency departments, inpatient acute care, labor and delivery, and perioperative services. Regardless of individual department or unique patient populations, certain approaches can be utilized across the enterprise including system-wide education, policy review, data analysis and engagement of SUD-focused community partners.

Summary

Boards can collaborate with their leadership to ensure the above strategies of prevention, treatment, harm reduction and recovery are in place and measured. Unhealthy substance use is a nationally recognized public health problem. Low-barrier access to SUD care in partnership with hospitals is part of the solution. While hospitals are not ideal environments for patients with SUD to receive long-term and maintenance care for addiction, hospitals are care environments equipped to care for people with acute physical and mental health crises. With appropriate interventions in hospitals, the nationwide crisis in treating and reducing substance use disorders can be addressed collectively and yield greater success. Governance engagement and action is a core component to improve care and outcomes for people with SUD.

The authors acknowledge colleagues from the AHA and Nicholaus Christian, M.D., addiction medicine fellow at Yale University, for reviewing this article and offering feedback prior to publication. Elements of the preceding article adapted from work conducted by the Colorado Hospital Association’s Clinical Leadership and Excellence Council and its group of SUD advisors.

Richard Bottner (richard.bottner@cha.com) is vice president, Clinical Excellence, at the Colorado Hospital Association based in Denver. Karla Hardesty (kjhardesty@gmail.com) is board chair, San Luis Valley Health in Alamosa, Colo. Korrey Klein, M.D., (kklein@fhw.org) is chief executive officer, Family Health West in Fruita, Colo.

Please note that the views of interviewees do not always reflect the views of the AHA.