Background: Previous studies have documented discriminatory refusals from post-acute care facilities related to opioid use disorder or opioid agonist therapy, however the impact of inability to secure skilled nursing facility (SNF) placement for patients with any substance use disorder (SUD) has not been fully explored. The objective of this study is to measure the odds of SNF referral failure for patients with SUD versus those without SUD and to compare the time spent inpatient awaiting disposition.

Methods: We reviewed administrative data for all patients discharged from a 400-bed, urban, public U.S. hospital from January 1st 2019 and January 1st 2021 who were also referred to SNF during hospitalization. Patients who died, left against medical advice, or transferred to another inpatient hospital were excluded. The primary outcome of interest, SNF referral failure, was defined as discharge to home/self-care. Presence of SUD in our administrative data reflects the presence of a dedicated flag entered in the electronic medical record by the patient’s care team as part of their standard process. Other independent variables related to patient demographics, socioeconomic markers, hospitalization details, and mental health comorbidity were also captured. Univariable analysis using chi-square test was conducted and variables with p ≤ 0.25 were then used to create a stepwise binary logistic regression model of the primary outcome. Secondary outcome data, time between referral to SNF and ultimate discharge, was summarized using median with interquartile range, and differences between groups were tested using Wilcoxon rank-sum.

Results: Our sample included 3,926 hospitalizations with 732 (18.6%) SNF referral failures. Patients with SUD experienced a higher proportion of SNF referral failure (278/800; 34.8% vs. 454/3126; 14.5%, p<0.0001) and remained inpatient longer between SNF referral and discharge than those without SUD (median 7.5 days [IQR 3-20] vs median 4 days [IQR 2-8], p<0.0001). In our fully adjusted model, SUD was an independent predictor of SNF referral failure with a 94% increase in odds as compared to patients without SUD (aOR 1.94; 95%CI 1.58-2.38).Other factors related to increased odds of SNF referral failure included homelessness (aOR 1.84; 95%CI 1.41-2.42), primary insurance (using Medicare as reference, Medicaid, private/commercial, and self-pay/uninsured all increased the odds of SNF referral failure), race/ethnicity (using white as reference; American Indian/Alaska Native aOR 1.59; 95%CI 1.03-2.45), and discharge from a surgical service (using discharge from medical service as reference: aOR 1.44; 95%CI 1.20-1.74). Older age (using <50 yo as reference: age ≧65 aOR 0.40; 95%CI 0.30-0.53) and any ICU days (aOR 0.72; 95%CI 0.61-0.87) were associated with reduced odds of SNF referral failures. Mental health disorder was not associated with SNF referral failure (aOR 1.18; 95%CI 0.98-1.43).

Conclusions: Patients with SUD referred for SNF placement during hospitalization were much more likely to discharge to self-care and remained longer in the hospital awaiting disposition than those without SUD. Together, these findings indicate that patients with SUD face barriers to post-acute care options. In addition, we identified factors such as homelessness and primary insurance that were independently related to our primary and secondary outcomes. System-level focus is required to meet these needs and to ensure equitable access to care facilities.

IMAGE 1: Table 1: Univariable Analysis of Failed SNF Referral and Days Between SNF Referral and Discharge

IMAGE 2: Table 2. Logistic Regression Model Predicting Odds of Failed SNF Placement