A Climate of Stigma, Uncertainty, and Distrust: Stakeholder Perception of Barriers to SNF Placement for Patients with Opioid Use Disorder Treated with Methadone

Background: Patients with opioid use disorder (OUD), especially those treated with methadone, face significant challenges to placement in a skilled nursing facility (SNF). Efforts to address this via legal actions have not resulted in improved access.

Objective: To understand regulatory and non-regulatory factors that impact SNF placement of patients with OUD treated with methadone.

Design: Observational qualitative study.

Participants: Stakeholders in the hospital-to-SNF referral process as well as those with specific expertise related to OUD.

Approach: Open-ended, semi-structured interviews.

Results: Interviews with 15 participants identified three key themes that function together in addition to logistic and financial barriers: (1) stigma and perception of risk, (2) uncertain regulatory environment, and (3) distrust between responsible entities. Fundamentally, many SNFs do not feel they can provide necessary care related to OUD and methadone. They tend to be disinclined to care for patients with OUD and express concerns about perceived risks such as overdose, violence, or discomfort to other residents. SNFs are also very motivated to avoid regulatory citations and fines related to OUD or methadone. Since confusion and misinformation about relevant policies and procedures is common, many opt to decline these patients. Compounding these challenges, entities responsible for coordinating care demonstrate poor communication and lack of transparency with each other. Referral and declination information sent between hospitals and SNFs is often considered to be incomplete or incorrect, and many hospitals have stopped referring patients with OUD treated with methadone to SNFs altogether. Regulatory bodies are often feared by healthcare providers and administrators and interaction is avoided. Finally, legal oversight representatives report that they do not receive sufficient information to properly investigate concerns.

Conclusion: This study identifies the climate of stigma, uncertainty, and distrust between responsible entities that stymies improvement efforts. Creation of meaningful reform must address each of these areas.