Barriers to Substance Use Disorder Treatment for People in Nursing Facilities

"Multiple structural and systemic barriers contribute to this care gap.6–8 Many nursing facilities are underresourced, experience high staff turnover, and lack training and incentives to care for residents with SUD [Substance Use Disorder]. Financing challenges also play a significant role: Although both Medicare and Medicaid cover nursing facility care for eligible residents, Medicare reimburses at higher rates for SNF services, often yielding positive profit margins compared with the losses associated with Medicaid.9 This payment imbalance contributes to selective admission practices that disadvantage younger patients with SUD, despite their having legitimate skilled care needs such as intravenous antibiotics or wound care.6 Regulatory uncertainty around MOUD and fears of fines and penalties further deter nursing facilities from providing treatment.7 In addition, coordination between nursing facilities and opioid treatment programs (OTPs), or clinics that dispense methadone for OUD, is often hindered by logistical challenges, such as transportation costs and restrictive regulations, creating significant MOUD access challenges.

"Stigma toward patients with SUD further exacerbates the problem, contributing to a well-documented pattern of admissions discrimination and denials at nursing facilities—a practice that has led to legal challenges.10–12 Patients denied placement face prolonged hospitalizations; increased health care costs; and disruptions in care, such as tapering off lifesaving MOUD or being switched to less effective treatments.5,10 When accepted, patients are often placed in lower-quality facilities lacking the capacity to meet their SUD needs.11 “Institutional mismatches”6 occur when patients are placed in settings that are ill prepared to provide necessary services, such as when a patient with OUD is denied outpatient parenteral antimicrobial therapy because they have an injection history, despite limited supporting data for this restriction,13 and is sent to a SNF that might not support continuation of the MOUD the patient receives in the community. Similarly, a medically complex patient may be discharged to a SNF instead of inpatient rehabilitation for SUD because of the addiction facility’s perceived inability to meet their medical needs. These mismatches reflect institutional biases that deepen disparities in care access and contribute to costly inefficiencies."