Historically, hospital administrators, national hospital associations, and the Joint Commission have provided limited attention and resources to the care of hospitalized patients with addictive disorders, especially those with OUD. However, in the midst of the opioid-related overdose crisis, attention to treatment in the hospital is growing [30]. National and state policymakers are beginning to address care deficits in this setting. The Centers for Medicare & Medicaid Services (CMS) now require the use of the American Society of Addiction Medicine (ASAM) levels of care for state Medicaid programs applying for §1115 waivers to redesign SUD delivery systems [31] and hospitals are a part of this care continuum [32]. Further, recent legislation in Massachusetts requires emergency department clinicians to offer and provide OAT to patients seeking care with an OUD [33]. This is a policy that could be readily extended to care delivery in the inpatient setting.
Unfortunately, interest in improving hospital care for patients with OUD and other SUDs, by and large, has not been driven by ethical, moral, and legal arguments. Our informants noted that these arguments were not sufficient for convincing most high-level hospital administrators to implement an AMC service. Garnering the support of high-level hospital leadership instead relied primarily on articulating how the service aligned with hospital goals and how the service could operate as a financially value-maximizing activity; thus, clinical champions pitched the service as a business proposition. How this information was gathered and subsequently packaged for presentation depended on the experience, expertise, and training of the addiction medicine physicians and available resources at each hospital.
The prevalence of U.S. AMC services is unknown and a centralized list or repository of service locations has yet to be created. There are several U.S. cities, health systems, hospitals, and academic health centers publicly promoting and publishing on the existence of their respective AMC services. In New York City, New York Health and Hospitals launched a city-wide program to implement six AMC services at six hospitals—the Consult for Addiction Treatment and Care in Hospitals (CATCH) program. The CATCH program has an evaluation plan in place and will be the first multi-site study on the effectiveness of AMC services [34]. Other institutions with public-facing programs include: Boston Medical Center [14], Massachusetts General Hospital [16], Oregon Health & Science University [12, 15, 20, 35, 36], and the University of Maryland [18].
At least two groups have circulated tools designed to improve care for patients with OUD and SUDs in the hospital setting—the California Bridge Program and the Improving Addiction Care Team (IMPACT) at Oregon Health & Science University. The California Bridge Program, affiliated with the Public Health Institute, provides open-source resources related to the care of patients with OUD and SUD in the hospital setting, including but not limited to: inpatient guidelines, order sets, patient materials, pharmacy and therapeutics committee materials, and OAT financing and billing resources [37]. The IMPACT team recently published a compendium of resources including medication management protocols (e.g., withdrawal protocol), assessment tools (e.g., social work SUD assessment), treatment tools (e.g., patient safety care plan), and other resources (e.g., sample letter to judge or parole officer) [35]. To date, neither group has published tools on how to make the AMC service business case to hospital administrators; thus, it is the synthesis of the findings from this study, paired with prior literature review [22], that informed the development of two tools to fill this gap: 1) an AMC service business case template (Fig. 1); and 2) an AMC service design and operations resource list (Fig. 2).
The purpose of Fig. 1 is to provide evidence and rationale to convince hospital administrators why an AMC service would benefit their respective hospital. Figure 1 includes a description of what an AMC service is, why a service should be created to help address the opioid-related overdose epidemic, and which organizations are national leaders of this care delivery intervention. Figure 2 is a list and summary of recently published resources related to AMC service design and operations to support clinical champions planning to launch a service.
The primary study limitation is transferability, because most hospitals in this sample were affiliated with urban academic health centers and had above average access to addiction-related resources (e.g., education, staff, research). The findings may be less applicable to hospitals without addiction medicine experts, addiction medicine trainees, or that exist in lower-resourced settings. Another study limitation was the heterogeneity of the involvement of the study key informants in AMC service establishment and operations. Differences in positionality, observer versus implementer, may influence the perceptions of the informant [38].
