Unplanned discharge is common in substance use disorder (SUD) residential programs and associated with worse outcomes such as relapse and suicide. There is high variation in unplanned discharge rates across Department of Veterans Affairs (VA) SUD residential programs. Little is known about program factors related to unplanned discharge in these settings. We aimed to discover staff beliefs about avoiding unplanned discharge and related harms in VA SUD residential programs.
Methods:
We identified VA sites with low (<10%) and high rates (≥30%) of unplanned discharge. Informed by the Theory of Planned Behavior, we conducted semi-structured interviews with staff members at sites to learn about staff beliefs about unplanned discharge and its related harms in SUD residential settings. Two analysts reviewed the data and employed a combination of directed-content analysis and inductive methods to identify themes stratified by high- versus low-rate sites.
Results:
We enrolled 10 sites (20 participants). There was high variability in how participants and sites operationalized unplanned discharge. Participants at low-rate sites generally emphasized harm-reduction approaches as useful ways to treat problematic behaviors that could result in an unplanned discharge. Participants at high-rate sites, on the other hand, favored the use of boards or councils to manage these concerns.
Conclusions:
SUD residential programs should standardize the way that they define and document unplanned discharge. Future research should study the role of harm-reduction strategies and councils in mitigating unplanned discharge and related harms.
BrookMHiltyDMLiuWHuRFryeMA.Discharge against medical advice from inpatient psychiatric treatment: a literature review. Psychiatr Serv. 2006;57(8):1192-1198. doi:10.1176/ps.2006.57.8.1192
2.
RibletNBGottliebDJWattsBVLevisMShinerB.Irregular hospital discharge from acute inpatient and residential mental health treatment settings in a large integrated healthcare system. Gen Hosp Psychiatry. 2021;72:7-14. doi:10.1016/j.genhosppsych.2021.06.009
3.
StenersenMRThomasKStrubleCMooreKEBurkeCMcKeeS.Termination from substance use disorder treatment in the United States: residential and outpatient settings. J Stud Alcohol Drugs. 2023;84(3):476-484. doi:10.15288/jsad.21-00221
4.
StahlerGJMennisJDuCetteJP.Residential and outpatient treatment completion for substance use disorders in the U.S.: moderation analysis by demographics and drug of choice. Addict Behav. 2016;58:129-135. doi:10.1016/j.addbeh.2016.02.030
5.
RibletNBGottliebDJWattsBVLevisMScottRShinerB.Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?J Nerv Ment Dis. 2022;210(3):227-230. doi:10.1097/nmd.0000000000001425
6.
BakerDEEdmondsKACalvertML, et al. Predicting attrition in long-term residential substance use disorder treatment: a modifiable risk factors perspective. Psychol Serv. 2020;17(4):472-482. doi:10.1037/ser0000333
7.
TisdaleCLeungJde AndradeDHidesL.What client demographic, substance use, mental health, treatment, and psychological variables predict residential treatment completion for substance use disorders?. Int J Ment Health Addict. 2023;23:49-69. doi:10.1007/s11469-022-01002-w
8.
DeckerKPPeglowSLSamplesCRCunninghamTD.Long-term outcomes after residential substance use treatment: relapse, morbidity, and mortality. Mil Med. 2017;182(1):e1589-e1595. doi:10.7205/milmed-d-15-00560
9.
RibletNBGottliebDJWattsBVLevisMShinerB.Association between suicide, external-cause and all-cause mortality and irregular mental health discharge among the US Veteran population. BJPsych Open. 2021;7(5):e162.
10.
KuoC JTsaiSYLiaoYTLeeWCSungXWChenCC.Psychiatric discharge against medical advice is a risk factor for suicide but not for other causes of death. J Clin Psychiatry. 2010;71(6):15885.
11.
AlfandreD.Improving quality in against medical advice discharges—more empirical evidence, enhanced professional education, and directed systems changes. J Hosp Med. 2017;12(1):59-60. doi:10.1002/jhm.2678
12.
AmbastaASantanaMGhaliWATangK.Discharge against medical advice: “deviant” behaviour or a health system quality gap?BMJ Qual Saf. 2020;29(4):348-352. doi:10.1136/bmjqs-2019-010332
13.
OnukwughaENagarajanMOffurumAGulatiMAlfandreD.Multi-level predictors of discharges against medical advice: identifying contributors to variation using an all-payer database. J Healthc Qual. 2021;43(1):e8-e19. doi:10.1097/JHQ.0000000000000252
14.
RibletNBGottliebDJShinerB, et al. An analysis of irregular discharges from residential treatment programs in the Department of Veterans Affairs Health Care System. Mil Med. 2023;188(11-12):e3657-e3666. doi:10.1093/milmed/usad131
15.
de AndradeDElphinstonRAQuinnCAllanJHidesL.The effectiveness of residential treatment services for individuals with substance use disorders: a systematic review. Drug Alcohol Depend. 2019;201:227-235. doi:10.1016/j.drugalcdep.2019.03.031
16.
McNeilRSmallWWoodEKerrT.Hospitals as a “risk environment”: an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med. 2014;105:59-66. doi:10.1016/j.socscimed.2014.01.010
17.
FeeneyLKavanaghAKellyBDMooneyM.Moving to a purpose built acute psychiatric unit on a general hospital site—does the new environment produce change for the better?Ir Med J. 2007;100(3):391-393.
18.
TongASainsburyPCraigJ.Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:10.1093/intqhc/mzm042
19.
RibletNBGottliebDJShinerBZubkoffLRiceKRuschB.Evaluating and identifying changes in the rate of unplanned discharge among Department of Veterans Affairs (VA) facilities providing substance use disorder residential care. J Subst Use Addict Treat. 2024;167:209514. doi:10.1016/j.josat.2024.209514
20.
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee to Evaluate the Department of Veterans Affairs Mental Health Services. Evaluation of the Department of Veterans Affairs Mental Health Services. National Academies Press (US); 2018.
21.
Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1162.02 Mental Health Residential Rehabilitation Treatment Program. Transmittal sheet. July15, 2019.
HenninkMKaiserBN.Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med. 2022;292:114523. doi:10.1016/j.socscimed.2021.114523
AjzenI.The theory of planned behavior: frequent asked questions. Hum Behav Emerg Tech. 2020;2:314-324.
26.
BosnjakMAjzenISchmidtP.The theory of planned behavior: selected recent advances and applications. Eur J Psychol. 2020;16(3):352-356. doi:10.5964/ejop.v16i3.3107
27.
JavadiMKadkhodaeeMYaghoubiMMaroufiMShamsA.Applying theory of planned behavior in predicting of patient safety behaviors of nurses. Mater Sociomed. 2013;25(1):52-55. doi:10.5455/msm.2013.25.52-55
28.
BhardwajASousaJLHuskampHA, et al. Prescribing medications for alcohol use disorder: a qualitative study of primary care physician decision making. Ann Fam Med. 2023;21(4):332-337. doi:10.1370/afm.2997
29.
HsiehHFShannonSE.Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288. doi:10.1177/1049732305276687
30.
GriesemerIPalmerJAMacLarenRZ, et al. Rural Veterans’ experiences with social risk factors: impacts, challenges, and care system recommendations. J Gen Intern Med. 2024;39(5):782-789. doi:10.1007/s11606-023-08530-8
31.
HawkMCoulterRWSEganJE, et al. Harm reduction principles for healthcare settings. Harm Reduct J. 2017;14(1):70. doi:10.1186/s12954-017-0196-4
32.
McCoyMLDevittTClayR, et al. Gaining insight: who benefits from residential, integrated treatment for people with dual diagnoses?Psychiatr Rehabil J. 2003;27(2):140-150. doi:10.2975/27.2003.140.150
33.
MaddenEFisherAMillsKLMarelC. Best Practice Approaches for Alcohol and Other Drug Treatment in Residential Settings. Evidence Check and Member Consult Commissioned and Managed by the Network of Alcohol and other Drug Agencies (NADA). The University of Sydney Matilda Center; 2020. Accessed October 31, 2024. https://nada.org.au/wp-content/uploads/2021/07/NADA-Evidence-Check_FINAL_09-03-2021.pdf
34.
ShieldsLBELaRoccoMYoungMWFlandersK. Using a harm reduction approach to treat inpatients with substance use disorders. J Nurs Adm. 2023;53(3):138-145. doi:10.1097/nna.0000000000001259
35.
MayesJHandleyS.Evolving a model for integrated treatment in a residential setting for people with psychiatric and substance use disorders. Psychiatr Rehabil J. 2005;29(1):59-62. doi:10.2975/29.2005.59.62
WhiteWLScottCKDennisMLBoyleMG.It’s time to stop kicking people out of addiction treatment. Counselor. 2005;6(2):12-25.
38.
WilliamsIL.Moving clinical deliberations on administrative discharge in drug addiction treatment beyond moral rhetoric to empirical ethics. J Clin Ethic. 2016;27(1):71-75.
39.
KeatingSLarsenSECollingwoodJSmithHM.The Individualized Addictions Consultation Team Residential Program: a creative solution for integrating care for Veterans with substance use disorders too complex for other residential treatment programs. J Dual Diagn. 2021;17(2):172-179. doi:10.1080/15504263.2021.1881685
40.
DavisKEDevittTRollinsAO’NeillSPavickDHardingB.Integrated residential treatment for persons with severe and persistent mental illness: lessons in recovery. J Psychoact Drugs. 2006;38(3):263-272. doi:10.1080/02791072.2006.10399852
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