For patients with addiction, nursing home care still has gaps

WORCESTER - Gregory Alger is not your typical nursing home patient. He's 36. He hopes to go back to work. And he's in recovery from substance use disorder, for which he takes buprenorphine, or Suboxone, daily.

Alger was admitted to Worcester Rehabilitation and Health Care Center in May, a skilled nursing facility on Vernon Hill, after a month-and-a-half-long stay at Fairlawn Rehabilitation Hospital and a hospital admission at UMass Memorial Medical Center.

WRHCC and Parsons Hill Rehabilitation and Health Care Center, also in Worcester, are owned by Athena Health Care Systems, a privately owned long-term care company based in Connecticut. The company has become one of the few in the region to offer programs to care for patients who have a history of addiction on top of the physical care diagnosis for which they are referred.

Alger considers himself lucky to be alive and, after a long struggle with drugs and run-ins with the law, is committed to carving out a healthy life for himself and others he can help.

"I feel like everything shut down for me," Alger said in an interview at the nursing home recently. "But it was like a reboot."

A concrete shoveler for the past 16 years, Alger, a Hudson High School graduate, said he got heavily involved with heroin, cocaine, "pretty much everything."

Even after getting out of jail in March, he said, "I guess I wasn't ready to stop that lifestyle."

He bought some cocaine, which had been laced with fentanyl and barbiturates.

Next thing, he was found face down in a parking lot in Framingham, not breathing. Paramedics tried to revive him and he flatlined twice, he said. He was rushed to a nearby hospital, where he was on life support and in a medically-induced coma for four days.

Alger said he discharged himself against medical advice and got on a commuter train to Worcester, where his father lives.

He went to bed at his father's but when he got up, he fell hard and was taken to UMass Memorial Medical Center, where he was "completely lifeless for about a week."

When he came to, Alger said, he was blind, couldn't walk and couldn't talk. He could only hear and nod his head. He was on a feeding tube.

Slowly his vision started to return and he was sent to Fairlawn for rehabilitation therapies.

While Alger was working on regaining his physical functioning, cravings for opioids continued. He asked to be on Suboxone, a prescription medication for treating opioid addiction that blunts the effect in the brain of drugs such as heroin or oxycodone. It also reduces cravings for opioids.

Rehabilitation hospitals work with patients to achieve therapy goals. But for long-term care, if a patient isn't able to live independently in the community, the patient typically goes to a nursing home.

Nursing homes are licensed by the state Department of Public Health and are surveyed by DPH to certify that they comply with federal Medicare and Medicaid regulations. They are not regulated as detoxification or addiction recovery centers.

Stephen Calvin, administrator at WRHCC, said the two Athena-owned facilities in Worcester are the only ones he knows of that have developed partnerships with drug treatment centers and in-house programs to train staff and support patients who also have substance use disorders.

"It's an excruciating problem," Peter Zawrotniak, program manager in addiction counseling services at UMass Memorial Medical Center, said about placing patients with substance use disorders in appropriate aftercare, particularly if they need methadone treatment.

It's a challenge the UMass team deals with almost every day.

Zawrotniak said none of the long-term care facilities in the area is equipped to address the full range of services needed for treatment and recovery.

Methadone, another form of medication-assisted treatment for opioid addiction, can only be administered to patients at a licensed methadone clinic. Patients must be registered with the clinic, a bureaucratic process that can be time consuming to coordinate. One patient waited in a hospital bed for two weeks. The nursing home must then transport the patient to the methadone clinic every day for their dose.

Suboxone, as long as it is prescribed by a physician with a waiver to do so, can be dispensed by nursing home staff and is easier to manage, Zawrotniak said.

"There are a lot of old laws guiding the process," Zawrotniak said, and those are obstacles to quick intervention.

The state DPH's Bureau of Health Care Safety and Quality issued a letter in 2016 about admission of residents on medication-assisted treatment for opioid use disorder. According to the letter, patients who have completed detoxification and are receiving medication-assisted treatment, and are otherwise eligible for admission to the long-term care facility, are expected to be admitted and have their treatment continued as prescribed by the patient's physician or opioid treatment program.

Still, Zawrotniak said, facilities often refuse to take these patients.

"It's a complex situation," said Helen Magliozzi, director of regulatory affairs for the Massachusetts Senior Care Association, which represents more than 400 nursing and rehabilitation facilities, assisted living residences, residential care facilities and continuing care retirement communities. "The barriers they're really up against are financial and regulatory, and lack of guidance."

Magliozzi said there is no federal guidance on what reasonable accommodations need to be made for patients with substance use disorders. And extra services such as addiction counselors and enhanced security measures are not reimbursed by Medicare or Medicaid.

"The federal regulations were really written to care for frail elders," she said.

"This is an unusual place," Calvin said of WRHCC. "It's not your grandmother's nursing home."

The 160-bed WRHCC has an average of 140 patients. Currently 94 patients have some sort of substance use disorder, including alcohol as well as opioid or other drug addiction, according to Calvin. The skilled nursing facility has a 40-bed unit dedicated to patients with substance use disorder, but many are placed in rooms throughout the facility.

WRHCC has partnerships for medication-assisted treatment, such as Suboxone or methadone, with CleanSlate and Spectrum Health Systems.

The nursing home has a full-time substance use disorder counselor, two social workers available for support and helping patients transition to the community, and an after-care coordinator who works with patients being discharged.

And, Calvin said, "The in-servicing is robust." All staff are trained not just on drugs and addiction, but also on related issues such as gangs and crime.

Security at the nursing home is also different from most other facilities. Two full-time security guards, who are not reimbursed under MassHealth payments, search people's bags for contraband when they come in. Cameras are placed throughout the facility, except in patients' rooms.

"It's a huge issue" that most skilled nursing facilities don't address, Calvin said. "I think we have been forerunners in it and we've gotten pretty good at it."

Calvin said referrals come from Boston, Springfield, Connecticut and elsewhere.

The nature of diagnoses that land patients in a nursing home may also make them vulnerable to succumbing to their addiction.

For instance, a patient may be admitted for intravenous antibiotics to treat infection resulting from injecting illicit drugs. A peripherally inserted central catheter, or PICC line, is the usual way to deliver IV antibiotics directly into a vein. It could also be an easy way to inject illicit drugs.

What's more, nursing home regulations require patients to be allowed to come and go at any time. The temptations outside can be hard to resist for someone struggling with addiction.

Calvin said that if a patient is observed with an altered mental status, a nurse conducts an assessment. If illicit drug use is suspected, the patient's room is searched for contraband. Patients found to be using or bringing in illicit substances are put on a safety plan and must have a responsible party along when leaving the building.

"We've found a way to manage these things so that it works for us," Calvin said.

Two years ago, before the program ramped up, there were six overdoses a day among nursing home patients, according to Dr. Matilde Castiel, Worcester's commissioner of health and human services.

"That has changed dramatically," she said.

Calvin said they now see one or two overdoses a month.

Staff are trained in delivering naloxone, or Narcan, an overdose-reversing drug.

Castiel said nursing home patients with substance use disorders who may not have started recovery also present an opportunity.

"This is a captured audience. How can we get them into treatment?" she said.

She said the Athena nursing homes offer "something that was truly needed for the hospitals" and she has met with the state DPH Bureau of Substance Addiction Services to encourage more partnerships based on that model.

"It's been a long haul," Castiel said. "It's a nursing home, but they're not nursing home patients."

Magliozzi said DPH is working with long-term care facilities on a Medication for Opioid Use Disorder grant, funded by the federal Substance Abuse and Mental Health Services Administration, to look at how to transition people with medication-assisted treatment into nursing homes.

"I think it's a journey," Magliozzi said. "Facilities have realized and recognized they need to care for this population. But I think there's more that needs to be done."

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