Optimizing care transitions to post-acute care following hospitalization for people with opioid use disorder

Abstract

Background and Objectives

Increased referrals to skilled nursing facilities (SNFs) from hospitalized people with opioid use disorder (OUD) carry risk for financial, safety, and legal consequences for poor transitions in care. We aimed to better understand the hospital to SNF referral process and identify opportunities to improve transitions and care for people with OUD, an increasing share of whom are older adults.

Research Design and Methods

Participants included administrative, executive leadership, and clinical staff involved in SNF admission decisions across the United States. To identify key themes, descriptive thematic analysis was used to analyze semi-structured interview data collected between March and October 2023.

Results

There were 29 participants from 27 SNFs in 19 states. We identified five themes. (1) Large variation in facility experience, stigma, and readiness to care for people with OUD: resources and willingness to care for people with OUD in SNFs varied with stigma, further impeding SNF access. (2) Conflation of OUD with pain management: participants struggled to distinguish between opioids for pain, OUD, and physiologic dependence, highlighting knowledge deficits about OUD. (3) Navigating information transfer: SNF staff screen referrals for challenges that could negatively impact patient care and perceive hospitals to sometimes omit important details to secure SNF placement. (4) Siloed regulations and care landscapes: regulatory structures complicated admissions and limited access to medications for OUD. (5) Building trust and managing expectations during transition: the hospital-to-SNF transition represents a crucial period for developing trust between people with OUD and SNF staff.

Discussion and Implications

Education about OUD and stigma, enhanced information transfer and care coordination, and regulatory reforms to expand access to medications for OUD in SNFs are needed to improve transitions and care for people with OUD in SNFs. Since SNF transitions increase with aging, these findings can inform efforts to address OUD in older adults.

Translational Significance.

This qualitative study with 29 skilled nursing facility staff identified knowledge deficits, including a variable ­understanding of opioid use disorder, stigma, information gaps, and opposing regulatory policies across settings that influenced SNF admission denials among people with opioid use disorder, an increasing share of whom are older adults with complex health needs. Improving transitions from the hospital to skilled nursing facilities for people with opioid use disorder requires immediate investment in basic opioid use disorder clinical knowledge, streamlined regulations across care settings, and standardized information sharing.

An increasing number of people with opioid use disorder (OUD) and skilled care needs following hospitalization requires hospitals and skilled nursing facilities (SNFs) to navigate timely and safe transitions between settings. Reasons for the growing demand for SNF care among people with OUD include rising rates of OUD and overdoses among adults over age 65, increases in chronic medical conditions among people with OUD, and complications of opioid use necessitating prolonged hospitalizations and post-acute skilled care such as rehabilitation, antibiotic therapy and wound care (Acevedo et al., 2022; Han et al., 2022; Mitchell et al., 2022; Ronan & Herzig, 2016; Shoff et al., 2021). Despite the growing need for SNF care for people with OUD, SNF settings accustomed to serving older adults may lack the necessary knowledge and resources to meet co-occurring addiction needs. People with OUD are more likely to be denied SNF admission than people without OUD (Cohen et al., 2023; Kimmel et al., 2022; Kuye et al., 2024; Moyo et al., 2024a; Wakeman & Rich, 2017) and to enter SNFs of lower overall quality relative to people without OUD (Moyo et al., 2024a).

Studies of SNF admission for people with OUD are largely drawn from limited geographic locations and precede the elimination of the buprenorphine X-waiver training requirement and settlements for discriminatory admissions practices by SNFs under the Americans with Disabilities Act (ADA), which protects people with OUD from discrimination by health care institutions (LeFevre et al., 2023; U.S. Attorney’s Office, 2023). Prior studies have reported individual (e.g., Medicaid insurance, younger age, housing instability, perceived violent or noncompliant behavior, and current or recent substance use) (Moyo et al., 2024b) and facility (staff shortages, insufficient training in OUD management, stigma, reimbursement, and SNF policies openly barring people with OUD from entry) (Kuye et al., 2024; Yang et al., 2023) level barriers to SNF admission for people with OUD from the perspective of SNF staff. Further, medications for opioid use disorder (MOUD) often contribute to SNF referral rejection for people with OUD due to staff perceptions of the inability to procure, store, prescribe, and administer MOUD (Cohen et al., 2023; Kuye et al., 2024; Yang et al., 2023).

SNFs and hospitals are at risk of financial (prolonged length of stay, rehospitalizations), patient safety (against medical advice [AMA] discharges, overdose), and legal consequences (ADA regulations) without adequate practices in place to meet the needs of people with co-occurring OUD and skilled nursing needs, which are increasingly prevalent among older adults (Cohen et al., 2023; Kim et al., 2020; Kuye et al., 2024; Shoff et al., 2021). The infrastructure for hospital-to-SNF transitions is poorly understood, particularly at the national level. Recent national movements toward value-based care and age-friendly health systems further motivate prompt discharge of hospitalized people with OUD from hospitals to SNFs, as appropriate, and developing capacity to provide access to MOUD to SNF residents (Jones et al., 2023). Optimizing hospital to SNF transitions for people with OUD and MOUD treatment continuity across care settings, particularly for older adults who are dying of drug overdoses at increasing rates, requires immediate attention (Humphreys & Shover, 2023; Spencer et al., 2024).

This exploratory study utilized semi-structured interviews with SNF staff from several states to examine barriers and facilitators to SNF transition and MOUD continuation after SNF admission. Our goals are to identify opportunities for policy and practice reform that build SNF capacity to serve people with co-occurring OUD and skilled care needs.

Methods

Recruitment

We recruited SNF staff from across the country using multiple approaches. First, we ranked SNFs nationally using Medicare data according to the number of beneficiaries admitted with OUD post-hospitalization and conducted telephone outreach to staff. Second, we identified all state long-term care ombudsmen listed on the website https://theconsumervoice.org/get_help and contacted them for referrals to SNF administrators. Third, research team members solicited referrals and employed snowball sampling in states with existing relationships with SNFs (Massachusetts, Connecticut, Pennsylvania). Lastly, we placed a recruitment advertisement for the study in the American Health Care Association Newsletter.

Data collection

We interviewed staff with various roles from SNFs of different characteristics and geographic locations and sought maximal variation rather than concentration. We prioritized recruitment of SNFs with higher OUD admission rates to increase the likelihood of uncovering potentially successful strategies for caring for SNF residents with OUD and limited the number of interviews conducted in a single state.

We developed a semi-structured interview guide based on the review of the literature and interdisciplinary research team input that included health services researchers, an addiction medicine physician practicing in hospital settings, a researcher in long-term recovery from addiction, a gerontologic nurse practitioner/researcher with extensive experience working in SNFs, and a geriatric pharmacist. The diverse methodological and content expertise of the research team provided a broad contextual understanding of hospital-to-skilled nursing transitions for people with OUD while also promoting reflexivity among team members’ individual perspectives. Interviews were conducted between March and October 2023 via Zoom, lasting approximately 45 minutes. Participants were given a $50 gift card honorarium. Sessions were recorded and transcribed via a transcription service. All interviews were conducted in English. The Brown University Institutional Review Board determined that the study did not qualify as human subjects research because participants were interviewed in their professional capacity.

Analysis

Interviews were analyzed using descriptive thematic analysis (Neergaard et al., 2009; Sandelowski, 2000). After conducting four interviews, two team members (CM, SN) independently generated a list of candidate codes through line-by-line open coding (Hsieh & Shannon, 2005). Lists were iteratively reconciled into a codebook. The remaining interviews were independently coded by two coders in NVIVO, who then reconciled the coding through an iterative process. After reconciliation, coded interviews were reviewed by a senior team member (AR, JS). When necessary, new codes were generated inductively. After all interviews were coded, the analysis team (PMD, AR, JS, CM, CR, SN) reviewed the coded interviews, as well as analytical memos, and independently generated themes. The full team then met to distill a final theme list through an iterative and reflexive process. Detailed documentation at all stages of analysis followed established guidelines to achieve trustworthiness in qualitative research (O’Brien et al., 2014).

Results

We interviewed 29 participants in 27 SNFs across 19 states (Table 1). Five themes were identified across participants (Tables 2 and 3).

Table 1.

Participant and facility characteristics.

Characteristic	n (%)
Participant characteristics (n = 29)
Role in skilled nursing facility
Administrator	19 (65.5)
Director of Nursing	6 (20.1)
Director of Admissions	1 (3.5)
Charge Nurse	1 (3.5)
Regional Vice President	1 (3.5)
Regional Clinical Director	1 (3.5)
Reported experience with OUD and/or medication for OUD
In current role	27 (93.1)
In previous role	1 (3.5)
None	1 (3.5)
Time in role at current facility in years
<1	5 (17.2)
1–5	19 (65.5)
6–10	3 (10.3)
>10	2 (0.07)
Facility characteristics (n = 27)
Geographic location (census region)
Northeast	10 (37.0)
Midwest	2 (0.74)
South	7 (25.9)
West	8 (29.6)
Facility ownership  a
For-profit	16 (59.3)
Nonprofit	8 (29.6)
Unknowna	3 (11.1)
No. of beds, mean (range)  a	137 (28–559)

Note. OUD = opioid use disorder.

^aThree participants worked for companies that oversaw several skilled nursing facilities. In these cases, facility ownership and bed count could not be calculated.

Table 2.

Themes, definitions, and illustrative quotations.

Theme and definition	Illustrative quotation(s)
Large variation in facility experience, stigma, and readiness to care for people with OUD
Knowledge about opioid use disorder (OUD), willingness to care for people with OUD, and what resources were necessary and available to do so varied across participants. Participants expressed dynamic and sometimes conflicting accounts of their experience, willingness, and ability to care for people with OUD. Key areas of variation included understanding addiction and addiction care and providing medications for OUD (MOUD).	See Table 3
Conflation of OUD with pain management
Participants frequently conflated opioids used for pain management, a diagnosis of OUD, and physiologic opioid dependence. Baseline difficulties with pain management in SNF are front of mind for SNF leadership (e.g., getting scripts promptly, adequate pain management following hospital dosing regimens, and the administration of PRN medication) and result in anxiety among staff and residents.	“We do have a couple people that go out to methadone clinics. I don’t know if that’s considered in the same drug class. It’s usually either because they need it for pain—it’s very interesting ‘cause I never did anything with drugs before, but I would say a good amount of our people do have oxy orders.” (Participant 5)
Navigating information transfer between the hospital and SNF
During information transfer, SNF staff are looking for potential challenges that would negatively impact patient care. Participants spoke about the sense that hospitals may leave out, intentionally or not, important pieces of information to increase the likelihood of admission to SNF. Administrators emphasize that they don't want to accept a person that the facility can’t care for, yet the process of admission includes very few objective processes or exclusion criteria with a reliance on hospital records.	“I think better documentation of behavior. I think a lot of times when the hospital knows that someone’s going to need to go to a skilled nursing center and they have someone that’s having behavior to those kind of things, they don’t document them well because if we don’t see that in the notes, then we can’t—we aren’t necessarily going to deny them, and so just making sure that the information that’s coming across is consistent and honest.” (Participant 16)
Siloed regulations and care delivery landscape
SNF administrators described balancing resident care needs with extensive regulations from state and federal government, many of which influence skilled nursing facility reimbursement. Participants expressed hesitation in admitting too many people with co-occurring OUD and psychiatric illness. Reports from upset residents or failure to comply with regulations could result in funding consequences, reduced star ratings, and further scrutiny from federal and state regulatory agencies.	“I think too, with the hospitals and us, we still are pretty siloed. I care the most about my existing population, and I care about them today. If here, in a month, the population will be different. Some will still be here, others will discharge, but I don’t have a responsibility for people that have discharged after they’ve left here. The hospital doesn’t either. That’s part of the broken system. I think we’re not really treating people as holistically as we could as they move through the continuum. We’re just treating them for that time that they’re here. I think that it’s reinforced by reimbursement and regulation.” (Participant 3)
Building trust and managing expectations during transition
Participants shared concrete examples of mishaps that occurred at the start of the admission of a resident with OUD. The process of transitioning from the hospital and onboarding at the SNF is a crucial time to develop a relationship of trust between residents and SNF staff. A few participants showed a depth of understanding for how anxiety-inducing, uncomfortable, and frightening the transition from hospital to SNF can be for people with OUD.	“I think that a lot of the times, to put it bluntly and as nice as possible, at the hospital, they don’t usually prepare them for the transition to skilled nursing. Sometimes, they will just change orders and change the timing of the orders, but they have a different set order time at the hospital than we do here. If you’re saying, oh, three times a day, it could be three times a day, it has to be spaced out by six hours. If the resident’s leaving at 2:00 p.m. and they’re used to getting their med at 6:00 p.m. but they’re not even here because transportation is really poor, until 7:00, then they’re already in a rickety old ambulance, in high pain, coming here, and we don’t have it yet because our pharmacy doesn’t deliver ‘til 8:00 p.m., so it’s a little bit rough, I think, sometimes, the first couple of days.” (Participant 5)

Table 3.

Quotations demonstrating variation in facility experience, stigma, and readiness to care for people with opioid use disorder.

Description of variation	Illustrative quote
Significant experience and readiness lacking stigma	“One of the biggest challenges we’ve seen in the last two or three years—and we had this even before COVID, was like you said, opiate use disorder. Out here you don’t really see a lot of treatment centers. There’s a few, but I think even they can’t really accommodate as many people that we have, that we’d like to sign up for treatment. We had to play a bigger part, by trying to accept as many as we can. But of course, at the end of the day, the amount of licensed beds we have is a predicament for that as well.” (Participant 26)
Some experience, stigma present, with lack of readiness	“The chief complaint that I received from staff that oversee people with opioid addiction is the behaviors associated with the withdrawal but not necessarily recognition of the withdrawal or empathy for that withdrawal, so, “They’re an asshole. He’s a prick. She’s a bitch. Will you give her her pills? Will you please give her her pills and shut her up? Is there anything that you can give this guy to shut him up? I’m tired of hearing it.” (Participant 14)
Minimal experience, willing to admit, some stigma	“We have a captive audience here that are really sick and really maybe ready to change, but we don’t offer ‘em the services necessary to get ‘em to change there. We have nurses here; we have social workers; we have custodians. We don’t run AA meetings every night here. We don’t run NA meetings every morning here. We don’t run in between, whatever, massage therapy. I don’t even know what they do in rehabs. I’m sorry. I’m making assumptions. We would love to add that to our programs.” (Participant 17)
Minimal experience, unwilling to admit, significant stigma	“I guess this is just my point of view, but they’ll do whatever they kinda need to do to get to that next high or whatever it may be, if things aren’t going the right way, if we don’t have the exact medication in, and I have to wait, and then they can get aggressive, or they can get—potentially, dangerous situations can occur, so we’re very careful. Again, we don’t specialize in the OUD.” (Participant 1)

Theme 1: large variation in facility experience, stigma, and readiness to care for people with OUD

Knowledge about OUD, facility willingness to care for people with OUD, and availability of the resources necessary to do so varied across participants, with conflicting accounts across these domains (Table 3). Concerns about staffing, safety, and following strict regulations were coupled with derogatory language and stigmatizing beliefs about people with OUD.

Most participants emphasized the need for further education on addiction care among their staff. Notably, several participants reported a lack of empathy among staff caring for people with OUD in facilities with little experience as well as in some who routinely cared for people with OUD, with requests for training to improve compassion for people with OUD.

Several participants indicated an unwillingness to admit residents treated with MOUD. The presence of stigma, regardless of the SNF’s MOUD and behavioral health resources, showed a major barrier to readiness to care for people with OUD. A few participants demonstrated a comprehensive, person-­centered approach to caring for people with OUD, which is evident in the institutional practices they reported and in the way they spoke about people with OUD.

Participants also varied in their capacity to provide addiction care. Concerns included additional requirements to accommodate MOUD and perceived safety concerns for residents and staff, ranging from highly stigmatizing views of people with OUD as “violent” to more pragmatic concerns over the presence of unauthorized substances on site. In contrast, others regularly prescribed MOUD or had the infrastructure to work with community organizations, such as opioid treatment programs, to continue MOUD in the SNF. Facilities with the capacity to provide SNF care to people with OUD reported a high volume of patients with OUD as well as existing partnerships with community providers with experience managing MOUD and organizations like pharmacies, transportation, and outpatient programs versed in OUD care.

Theme 2: conflation of OUD with pain management

Participants frequently conflated active OUD, treatment with opioids for chronic pain, and physiologic opioid dependence associated with long-term opioid treatment. Many responded to questions about the admission of people with OUD to SNFs with concerns around pain management (e.g., getting prescriptions promptly, adequate pain management following hospital dosing regimens, administering as-needed [PRN] medication, and approaches to reducing high doses of opioid pain medications). Stigmatizing language (e.g., “drug seeking”) and generalizations of people with OUD as demanding or “agitated” were common. When asked to estimate the number of people with OUD admissions, one participant responded:

I don’t know about the disorder, but they’re all coming in with prescriptions for opioids … A lot of them have been on opioids all their lives, and they’re not going to get off of it now. A lot of them are coming in for pain, whether it’s abdominal pain, back pain, shoulder pain. Literally, 9 out of 10. Everybody comes in with an order for some type of opioid. (Participant 9)

Theme 3: navigating information transfer between hospitals and SNFs

Participants reported looking for clinical characteristics that could make SNF patient care more challenging when reviewing referral records from hospitals. Participants noted that records often lacked key clinical details about people with OUD, which they attributed to hospital staff withholding information they perceived may lead a SNF to decline a referral, such as the recency of substance use, housing insecurity, serious mental illness, and behavioral concerns (e.g., elopement, prior acts of aggression toward staff). Some administrators reported scanning hospital medical records, the primary source of referral information, for evidence of “drug seeking,” suggesting that stigmatizing language in clinical notes can travel across clinical settings and affect decision-making in other contexts:

I would say probably lack of supporting documentation would be a reason why we would deny, or drug-seeking behavior from the patient that’s evident by clinical record, or based upon review and assessment, the clinician who assesses the patient notices some of those behaviors that would make them, you know, maybe not a good fit for our environment because that’s not what we specialize. That’s not who we serve. (Participant 21)

Participants emphasized that they were disinclined to accept someone who the facility could not care for safely, with limited specific examples of dangerous situations due to behavioral issues. Participants viewed addiction care as a specialized skill, different from their baseline experience serving older adults with physical and cognitive needs, and often overlooking the possibility of co-­occurring OUD among older adults. Participants expressed younger age as a clinical indicator that might make it difficult to care for people with OUD in SNF, describing perceived difficulties in caring for ambulatory younger adults with OUD and older adults with mobility and cognition deficits in the same environment.

Theme 4: siloed regulations and care delivery landscape

Participants described balancing resident care needs with extensive regulations from governing agencies, many of which influence SNF reimbursement. Areas of concern included abiding by SNF resident rights, constraints in the administration of PRN medications, managing behavioral health needs, and fear that providing necessary care to people with OUD could result in fines or citations. Concerns about providing OUD care were superimposed on an already strained system with the impacts of COVID-19, staffing shortages, and underfunding. Staying within the bounds of mandated restrictions on medication use and dosage while ensuring residents are “stable” was a major concern for participants, sometimes used as justification for denying admission of people with OUD:

They would have to find another medication that’s gonna meet their needs, keep them stable in order for us to accept. Otherwise, the nursing home will get dinged by the Center of Medicaid and Medicare…. (Participant 12)

Participants expressed hesitation to admit people with OUD when they perceived SNF regulations could penalize the facility. Specifically, participants cited the Preadmission Screening and Resident Review (PASRR) form and regulations around prescribing antipsychotics as barriers to admitting people with co-occurring serious mental illness and OUD. Reimbursement also exacerbated challenges in serving people with OUD with intact physical function as funding based on acuity often did not provide adequate SNF reimbursement to support care needs. Many participants described hospital regulations as a kind of “free-for-all,” where restrictions on medications and scrutiny from regulatory agencies are less of a concern when compared to SNFs. Some highlighted differences in restrictions, including the use of chemical restraints, 1:1 supervision, and pain medications, noting frustration that SNFs are left to treat patients without the tools hospitals use.

Theme 5: building trust and managing expectations during transition

Participants viewed transitions from the hospital to the SNF as a crucial window to build trust between SNF residents and staff. Participants shared concrete examples of failures in care continuity experienced by people with OUD during the transition period that resulted in additional staff work, frustrations between SNF staff and residents, and the risk of residents leaving AMA. SNF administrators often viewed the medical needs of people with OUD as subjective desires, overlooking the impacts of anticipated stigma and the anxiety-inducing potential of opioid withdrawal during the transition. In addition, participants expressed concern about a lack of social support impairing communication and planning when caring for people with OUD, as caregivers are commonly relied upon in SNFs to answer questions, support care, and facilitate transitions back home.

The discrepancy between hospital and SNF practices around pain medication dosing and timing sometimes created a problematic start to an admission. Abrupt changes in dosage or “cold turkey” withdrawals before hospital discharge were challenging when the SNFs could not meet resident needs and expectations around medication (e.g., intravenous pain medications, PRN medications, higher dosages, MOUD). Timing of admissions, particularly late-night or weekend admissions, exacerbated problems by making it difficult for SNFs to receive timely medication clarification from the hospital and fill prescriptions from pharmacies. Participants observed that transition problems risked setting the “tone” for the relationship between residents and SNF staff.

Despite challenges, participants also shared successful strategies for smoother transitions, including expectation setting around medication timing: “Once you assure them that the medication that they’ve been on will be available to them, they’re much less reluctant to being in a skilled nursing facility, much less. It’s starting off on the right foot” (Participant 7). Other beneficial strategies included the use of hospital liaisons, clear onboarding protocols for people with OUD, and early collaboration between the hospital, patients, and their families.

Discussion

This national qualitative study of SNF staff involved in admission decisions identified challenges and successful approaches in the transfer process for people with OUD to post-acute care. Findings demonstrated variability in the perceived readiness of SNFs to provide care for people with OUD, deficits in knowledge about OUD and MOUD, and widespread stigma toward people with OUD intertwined with ageism. The nuanced perspectives of SNF staff revealed the complex interplay of knowledge and resource deficits, misaligned regulations across settings, and entrenched stigma underlying disparities in access to SNF for people with OUD despite ADA protections (Kimmel et al., 2022; Moyo et al., 2024a). Poor transitions in care for people with OUD are costly and inefficient and associated with substantial morbidity and mortality (Benheim et al., 2025; Han et al., 2022; Moyo et al., 2022). Investment in workforce development, standardized SNF care pathways for people with OUD, and streamlined regulations across settings are required to address inequities.

Our findings likely underreport barriers to SNF care for people with OUD. The implications of U.S. Department of Justice protections for people with OUD potentially prevented participants from disclosing overt refusal to accept people with OUD to SNF, as this form of discrimination is illegal under the ADA (Nishar et al., 2024). Additionally, a lack of basic knowledge about OUD may have exacerbated the conflation of opioids with OUD and appropriate care, underscoring the importance of education as a foundation for policy reform. Improving skilled nursing care for people with OUD will require a regulatory landscape that enables collaboration across providers without fear of punitive consequences and funding for new approaches to meet the needs of people with OUD and SNF providers.

Challenges to providing care for people with OUD in SNFs also reflect resource capacity gaps. SNF staff expressed reservations about admitting someone when any doubt in their ability to promptly obtain necessary medications existed, consistent with other studies (Bann et al., 2024). Participants often viewed MOUD, and opioid analgesic medications more broadly, as a barrier to accepting and providing care for people with OUD. Federal restrictions in dispensing methadone create a burden for SNFs seeking to provide care to people with OUD in some facilities. Currently, SNFs need a designated opioid treatment program to reliably obtain methadone and processes to seamlessly collaborate with such programs. With the removal of federal X-waiver requirements, providers are less restricted from administering buprenorphine in SNFs. However, access to buprenorphine remains dependent on the clinician’s willingness to prescribe, potentially absent among many geriatric providers in SNFs (Lowenstein et al., 2025). SNF providers may continue to deny admission, and people with OUD may refuse to go to SNFs or leave prematurely without processes to efficiently deliver MOUD in post-acute care settings. Strategies suggested by participants to improve access to MOUD in SNFs included enhancing the capacity to dispense methadone from SNF pharmacies for OUD management, formal partnerships with community outpatient treatment programs, and the inclusion of addiction medicine providers within SNFs.

Discrepancies in regulations for SNFs, behavioral health treatment facilities, and hospitals present an additional barrier to caring for people with OUD. More lenient regulations in hospitals related to medication prescribing and staffing are not available in SNFs. Admission requirements in SNFs that single out mental health diagnoses, such as the PASRR form used during admissions for people with serious mental illness and intellectual disabilities, conflated OUD with mental healthcare. Study participants associated providing care to people with OUD with the need for special policies, such as procedures to address drug possession and visitation. This stigmatizing perspective generalizes the behaviors of some individuals to all with OUD and overlooks the co-occurrence of OUD and aging. Simultaneously, it reflects the importance of consistently identifying people who would be best served in a SNF and the need for clear, consistent protocols around issues such as non-­prescribed substance use. Environments that can deliver both behavioral health and physical healthcare would better serve people with OUD and the workforce, though they require regulatory reform.

SNF staff expressed the need for hospitals to provide timely, accurate clinical information and desired more investment in care coordination from the hospital once the person arrived at the SNF. Yet, interoperability of electronic medical records (EMRs) across settings enables incomplete, biased, and stigmatizing clinical records to transcend settings, potentially exacerbating disparities in care delivery and health outcomes for people with OUD. Suggested strategies to improve the flow of information to SNF included the use of SNF-hospital liaisons to coordinate discharge planning, shared EMR systems paired with education on derogatory language, and ongoing communication with hospital staff after discharge.

Funding co-located, skilled, OUD-specialized care, especially for those with co-occurring homelessness and other complex social needs, could improve care delivery and outcomes for people with OUD. Longitudinal support from multidisciplinary specialists was requested by SNF staff. Suggestions from SNF staff included reimbursement for specialty care for people with OUD, designated units for people with OUD who require SNF care in areas with a high prevalence of OUD, and embedding behavioral health staff and services within SNF settings, a practice already happening in skilled nursing facilities operated by the Veterans Health Administration (Strong et al., 2022).

Lastly, baseline understanding of OUD, MOUD, and opioid withdrawal symptom identification and management was absent across many participants, highlighting the need for additional education on these topics among SNF providers. SNF staff may also benefit from education around trauma-informed care and training about implicit biases to improve interactions with people with OUD (O’Malley et al., 2023). Investment in interdisciplinary OUD training across settings would provide the necessary foundation for equitable access to appropriate care. While evidence of the need for staff education and care coordination for people with OUD and skilled nursing needs is growing, few training programs address this gap. Provider toolkits to improve the delivery of care in SNFs for people with OUD, such as the one developed in Massachusetts, offer a starting point for tangible next steps in research, policy, and practice (Commonwealth of Massachusetts, 2025).

Limitations

Qualitative descriptive methodology facilitated the identification of emergent themes across diverse contexts but did not provide in-depth contextualization facilitated by concentration on a specific setting or allow for theory generation. Our sample size did not allow us to explore how perspectives might differ based on characteristics like participant role in SNF and facility ownership. Given guidance from the U.S. Department of Justice and settlements against SNFs under the ADA, some SNFs may have declined participation or underreported discriminatory practices.

Conclusion

Increases in the prevalence of OUD hospitalizations and inequities in access to SNF care for people with OUD warrant immediate policy and practice reform. Barriers to care for people with OUD and skilled care needs affect people of all ages, with magnified consequences for the growing number of older adults with OUD at higher risk for poor health outcomes. The perspectives of SNF staff in this study provide several focus areas to improve transitions from the hospital to SNF for people with OUD, including equitable regulations and resources to provide MOUD across health settings, co-located interdisciplinary SNF care delivery with behavioral and addiction specialists, and improvements in information exchange across settings. Addressing inequities in access to SNFs for people with OUD will require foundational knowledge of the treatment of OUD among SNF staff and funding models that support care for people with OUD across settings. Persistent challenges in delivering care for people with OUD who require SNF care across the U.S. compel urgent action.

Data availability

Our data are in the form of qualitative interview transcripts. For the sake of our participants’ privacy, we choose to keep data confidential.

Funding

This work was supported by the National Institutes of Health [R21DA053518] and [K23DA054363].

Conflict of InterestA. Z. Ritter served as a co-editor for the special issue, in which this article is published, but was not involved in the review or decision for the article. All other authors have no conflicts to declare.

Disclosure

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.