The navigation service aims to decrease hospital readmissions and, ultimately, increase positive addiction outcomes
By Jason LangendorfMay 6, 2021
For years, Jan Gryczynski, Ph.D., a senior research assistant at the Friends Research Institute, has sought to identify and solve service and treatment problems in the addiction space, working with a variety of populations to find new strategies that improve outcomes. You might call him an addiction-systems troubleshooter, especially in light of a treatment tool he’s developing called Navigation Services to Avoid Rehospitalization (NavSTAR).
Recently, Gryczynski and a group of colleagues attempted to tackle one of the most vexing issues in modern addiction treatment: addressing the gap in post-discharge services for people admitted to hospitals for reasons related to alcohol or drugs. The Maryland-based researchers conducted a randomized trial, the results of which were published in April in Annals of Internal Medicine, that focused on the efficacy of patient navigation services in reducing hospital readmissions among patients with substance use disorder.
“The hospital where we were working, at the University of Maryland Medical Center [UMMC], had a long-standing addiction consultation service that was one of the oldest such services in the country, and they provided really high-quality services for patients during their inpatient admission,” Gryczynski says. “But their capacity was kind of limited in the services they could provide after discharge, and as is typically seen with this population, we were seeing the same patients come in and out of the hospital over and over again. Some of those readmissions were directly related to the patient’s underlying substance use disorder. In other cases, it was a contributing factor.”
NavSTAR used proactive case management, advocacy, service linkage, and motivational support to resolve internal and external barriers to care and address SUD, medical, and basic needs for three months after discharge.”—study on NavSTAR in “Annals of Internal Medicine”
The objective of Gryczynski’s group: Learn whether smarter patient tracking—in this case, NavSTAR combined with a suite of effective existing services—would help keep substance use disorder (SUD) patients out of hospitals and reduce their need for follow-up healthcare services. As the Annals of Internal Medicine article states about the study, “NavSTAR used proactive case management, advocacy, service linkage, and motivational support to resolve internal and external barriers to care and address SUD, medical, and basic needs for three months after discharge.”
SUD’s Place in the Healthcare System
The strained relationship between healthcare systems and patients with SUD is one of medicine’s hairiest problems. People with SUD are at risk for overdoses and infections, and tend to suffer more acute and chronic health problems than the non-SUD population. Some SUD patients also visit emergency rooms and urgent care centers seeking medication for the purpose of diversion, tying up hospital resources. This only reinforces stigma toward patients with SUD, especially since many critical care workers are untrained to administer appropriate addiction treatment.
Comprehensive figures are difficult to pin down, but multiple studies over the years have found a rate of admissions to intensive care units related to SUD to be about 25%. One recent assessment put the annual medical cost associated with SUD in U.S. emergency departments and inpatient settings at more than $13 billion. The takeaway: Hospitals get overleveraged, providers and taxpayers are on the hook for the costs, and patients with SUD experience poor outcomes. In other words, everyone loses.
In the UMMC study, which followed 400 hospitalized adults with comorbid SUD (opioids, cocaine or alcohol), Gryczynski’s group witnessed frequent readmissions, including, on several occasions, the admission of the same patient at a different hospital on the same day. “I wouldn’t have believed [that] if I hadn’t seen the records,” Gryczynski says. “I mean, it was that level of really high-volume service utilization.”
When integrated with existing local services, including “advocacy, service linkage and motivational support,” NavSTAR yielded promising results in the UMMC study. Gryczynski calls NavSTAR “a fairly low-tech intervention.” Its framework is meant to be intuitive for addiction caregivers: Keep track of patients with SUD, know their backgrounds to better understand their needs, offer intervention and social services as needed, and stay connected. If at first you don’t succeed, try, try again.
Study participants had high levels of acute care use, but compared to treatment as usual (TAU), the NavSTAR-powered program helped reduce admissions for inpatients (from an 8.13 event rate per 1,000 person-days to 6.05) and emergency room visits (from 27.85 to 17.66). Patients were also less likely to have an inpatient readmission within 30 days (15.5% vs. 30.0%) and more likely to enter community SUD treatment after discharge within three months (50.3% vs. 35.3%).
A lot of hospitals are setting up these kinds of specialty addiction consult services, or increasing their addiction medicine capacity. [With] the recent changes in buprenorphine prescribing rules, I think you’re going to really open up a lot more access and opportunities for providing bridge medication for treatment linkage.”—Jan Gryczynski, Friends Research Institute
The UMMC study leveraged a regional network covering a relatively small area and patient population, but Gryczynski (who calls himself an optimist) believes the potential is there for systems such as NavSTAR to be brought to bear across a broader scope. “It doesn’t take very much for an intervention like this to pay for itself,” he says.
In the end, the success of programs such as NavSTAR may hinge on the quality of surrounding services and regional imperatives rather than cost or implementation logistics.
“In this hospital, addiction medicine is very much in the lifeblood of normal service delivery,” Gryczynski says. “That’s not going to be the case throughout the country. But I think that’s changing. A lot of hospitals are setting up these kinds of specialty addiction consult services, or increasing their addiction medicine capacity. [With] the recent changes in buprenorphine prescribing rules, I think you’re going to really open up a lot more access and opportunities for providing bridge medication for treatment linkage. I think there’s a lot that can be done in this area. It’s pretty exciting.”
Top photo: Tony Pham