SHM Converge Scientific Abstract ePoster Gallery-Improving Follow Up Care for Medicine Inpatients With Substance Use Disorders

Pdf Summary

This quality improvement project at VA Palo Alto Health Care System aims to improve discharge follow-up for medicine inpatients with substance use disorders (SUD), including alcohol-, opioid-, and stimulant-related diagnoses. The team’s SMART goals are to increase the percentage of patients with 30-day follow-up scheduled with General Medicine Clinic, Mental Health Clinic (MHC), or Addiction Treatment Services (ATS) by 10% from a baseline of 77.5%, and to increase specialty follow-up with MHC or ATS by 10% by September 2025.<br /><br />The project addresses a major care gap: SUD is associated with high healthcare costs, increased readmissions, longer hospital stays, and frequent ED use, while many patients do not receive treatment despite significant need. Local data showed low follow-up rates, especially for specialty SUD care. The team identified key barriers including complex scheduling processes, limited awareness of SUD resources, and inconsistent follow-up planning across inpatient teams.<br /><br />Interventions included creating a substance use disorder resource flyer, discussing follow-up during interdisciplinary huddles, establishing a scheduling process for open-access MHC appointments, creating an ATS Teams channel to facilitate scheduling, and providing education for social workers, hospitalists, and residents. Additional supports included a SUD-focused discharge order set and incorporating a SUD follow-up care plan into the discharge summary. The project also emphasized offering medication-assisted treatment and harm reduction resources.<br /><br />Early results showed improvement. Any 30-day follow-up increased from 77.5% pre-intervention to 89.3% post-intervention. Follow-up with ATS rose from 14.9% to 42.8%, and follow-up with MHC increased from 25.5% to 43.0%. Overall, the project suggests that coordinated, multidisciplinary discharge planning can substantially improve connection to ongoing SUD care.

Asset Subtitle

Nazima Allaudeen

Meta Tag

Author List Alejandra Picazo, Charmaine Seludo, Darryl Silva, Elaine Depadua, Kate Abed, Nazima Allaudeen, Samantha Bennett-Garcia, Sushmitha Divakar, Tabitha Miller, Thao Thanh Vu

Category Innovations

Concept Follow-up Care

Concept Substance Use Disorder

Concept 30-day Follow-up

Concept Addiction Treatment

Concept Treatment Engagement

Distinguished Non-Finalist

Presenter Organization VA Palo Alto Health Care System

Presenting Author Nazima Allaudeen

Track Quality Improvement

Keywords

substance use disorders

discharge follow-up

VA Palo Alto Health Care System

medicine inpatients

mental health clinic

addiction treatment services

quality improvement

harm reduction

medication-assisted treatment

care coordination

Follow-up Care

Substance Use Disorder

30-day Follow-up

Addiction Treatment

Treatment Engagement