'Advocates' Make ED Addiction Referrals Easier

BETHESDA, MD. – Personnel dedicated to screen, conduct brief interventions, and refer patients for alcohol and drug problems and other risky behaviors can make an important addition to the emergency department, according to investigators at Yale-New Haven Hospital.

In the Yale-New Haven (Conn.) program, called Project ASSERT, “health promotion advocates” (HPAs) relieve ED practitioners such as nurses, physicians, and physician assistants from conducting time-intensive visits with alcohol or drug abusing patients.

“It took people a little bit of time to get used to [the HPAs] and know that they were there, but once they saw what was happening where they were able to do these referrals and get patients out of the emergency department to a treatment facility, they saw it as beneficial,” said Linda C. Degutis, Dr.P.H., codirector of Project ASSERT (program for improving Alcohol and Substance Abuse Services and Educating Providers to Refer Patients to Treatment.)

Project ASSERT has received so much support from ED staff and the New Haven community that the hospital now completely funds the program outside of any grants, Dr. Gail D'Onofrio said at the annual conference of the Association for Medical Education and Research in Substance Abuse. Project ASSERT is funded by HPA consultation fees that are included in the hospital's billing processes.

The HPAs appear to have had a substantial impact on the patients they see. As many as 87% of the patients who were referred by the HPAs to specialized treatment centers for alcohol or other drug problems during 1999–2004 actually enrolled in treatment programs, said Dr. D'Onofrio, codirector of Project ASSERT.

Reports have shown that patients who present to the ED are more likely to have substance abuse problems than are those who present in a primary care setting, and less than 1% of ED patients with a diagnosis of substance abuse actually report it in the ED, said Dr. D'Onofrio, of the emergency medicine department at Yale University, New Haven.

In most EDs, practitioners do not routinely screen for drug and alcohol problems in patients who are not acutely intoxicated or do not ask for detox. “If someone comes in with an ankle sprain, [ED staff] are not asking them about alcohol and other drugs,” Dr. Degutis said in an interview. “That's where HPAs will do some screening and identify things that aren't generally identified by the staff.”

Time constraints prevent screening every patient who comes through the ED, but ED practitioners know that patients with certain diagnoses are more likely to have a problem, such as those with trauma.

The HPAs' duties include screening patients for at-risk alcohol and substance use or dependence, providing brief early interventions, and then referring ED patients to treatment programs. They also screen for selected health problems, domestic violence, and depression.

The program uses an equivalent of 2.8 full-time employees from 7 a.m. to 11 p.m. weekdays, 7 a.m. to 7 p.m. Saturdays, and 7 a.m. to 3:30 p.m. Sundays. So far, only one of the advocates is fluent in Spanish.

“It's important to know that when you try to do something like this in any place, it's really the people you hire, not particularly all your expertise” that makes the program work, Dr. D'Onofrio said at the conference, which also was sponsored by Brown Medical School. HPAs at Yale-New Haven came from jobs in occupational therapy, the department of public health, and addiction services, where they showed that they can relate well and are motivated to do that, she said.

HPAs “are not necessarily people with extensive education and training–that's not the requirement,” Dr. Degutis said. “The requirement is more that they're familiar with the community, are interested in working with a range of people, are committed to working in the area of substance abuse, and have good interpersonal skills.”

Initially, HPAs screened all patients who were suspected of alcohol or drug use at the beginning of the program. After the program was more established, however, emergency practitioners screened some patients and sent them to the HPAs for brief interventions and referrals. HPAs still screen patients if they are not in the midst of taking care of patients who have been referred to them, said Dr. Degutis, associate professor of emergency medicine at the university.

The HPAs perform a brief, 10–15 minute intervention for anyone with a risky behavior and then refer to a variety of services in primary care, psychiatry, or social work. Alcohol use is gauged with the CAGE test and criteria from the National Institute on Alcohol Abuse and Alcoholism.

Of 22,923 patients screened for alcohol and other drug problems during December 1999 through December 2004, 10,255 (45%) reported using alcohol. Among the 5,243 patients who exceeded low-risk criteria set by the NIAAA, 43% (2,258) met the NIAAA criteria for at-risk or hazardous drinking or reported no more than one of the CAGE criteria. A total of 58% (3,085) were dependent on alcohol, based on meeting two or more CAGE criteria. About 15% of all the patients who were screened reported illicit drug use.

The HPAs performed brief interventions for 7,196 patients and referred 3,571 patients to specialized treatment facilities, mostly for problems with alcohol (59%), but also for drugs (28%) or both (13%).

At 1 month after presentation to the ED, the investigators were able to account for 74% of the referred patients either by talking with the patient directly on the phone or by calling the referred treatment facility. Of those who were contacted, 87% enrolled in a treatment program. Even if none of the patients who were not contacted enrolled in a treatment center, 64% of referred patients still enrolled in a treatment facility.

The Boston Medical Center ED, which originally started Project ASSERT as a demonstration project in 1993, runs a program similar to the one at Yale-New Haven. Several other hospitals around the country are trying to develop programs modeled after Project ASSERT.

One program is in its beginning stages at the Hospital of Saint Raphael, New Haven. So far the program has had some difficulty gaining support from ED staff at Saint Raphael, said Dr. Degutis. Unlike the HPAs at Yale-New Haven, the HPAs at Saint Raphael are not part of the ED staff. They are instead hired by the department of psychiatry at the hospital.

These HPAs have name badges with “psychiatry” printed on them, which “may change the way that the patient views them” when they go to ask a set of screening questions, Dr. Degutis explained. HPAs at Yale-New Haven have name badges printed with “Project ASSERT,” so that they can tell patients that they are part of a screening project to look for health risks.

BETHESDA, MD. – Personnel dedicated to screen, conduct brief interventions, and refer patients for alcohol and drug problems and other risky behaviors can make an important addition to the emergency department, according to investigators at Yale-New Haven Hospital.

In the Yale-New Haven (Conn.) program, called Project ASSERT, “health promotion advocates” (HPAs) relieve ED practitioners such as nurses, physicians, and physician assistants from conducting time-intensive visits with alcohol or drug abusing patients.

“It took people a little bit of time to get used to [the HPAs] and know that they were there, but once they saw what was happening where they were able to do these referrals and get patients out of the emergency department to a treatment facility, they saw it as beneficial,” said Linda C. Degutis, Dr.P.H., codirector of Project ASSERT (program for improving Alcohol and Substance Abuse Services and Educating Providers to Refer Patients to Treatment.)

Project ASSERT has received so much support from ED staff and the New Haven community that the hospital now completely funds the program outside of any grants, Dr. Gail D'Onofrio said at the annual conference of the Association for Medical Education and Research in Substance Abuse. Project ASSERT is funded by HPA consultation fees that are included in the hospital's billing processes.

The HPAs appear to have had a substantial impact on the patients they see. As many as 87% of the patients who were referred by the HPAs to specialized treatment centers for alcohol or other drug problems during 1999–2004 actually enrolled in treatment programs, said Dr. D'Onofrio, codirector of Project ASSERT.

Reports have shown that patients who present to the ED are more likely to have substance abuse problems than are those who present in a primary care setting, and less than 1% of ED patients with a diagnosis of substance abuse actually report it in the ED, said Dr. D'Onofrio, of the emergency medicine department at Yale University, New Haven.

In most EDs, practitioners do not routinely screen for drug and alcohol problems in patients who are not acutely intoxicated or do not ask for detox. “If someone comes in with an ankle sprain, [ED staff] are not asking them about alcohol and other drugs,” Dr. Degutis said in an interview. “That's where HPAs will do some screening and identify things that aren't generally identified by the staff.”

Time constraints prevent screening every patient who comes through the ED, but ED practitioners know that patients with certain diagnoses are more likely to have a problem, such as those with trauma.

The HPAs' duties include screening patients for at-risk alcohol and substance use or dependence, providing brief early interventions, and then referring ED patients to treatment programs. They also screen for selected health problems, domestic violence, and depression.

The program uses an equivalent of 2.8 full-time employees from 7 a.m. to 11 p.m. weekdays, 7 a.m. to 7 p.m. Saturdays, and 7 a.m. to 3:30 p.m. Sundays. So far, only one of the advocates is fluent in Spanish.

“It's important to know that when you try to do something like this in any place, it's really the people you hire, not particularly all your expertise” that makes the program work, Dr. D'Onofrio said at the conference, which also was sponsored by Brown Medical School. HPAs at Yale-New Haven came from jobs in occupational therapy, the department of public health, and addiction services, where they showed that they can relate well and are motivated to do that, she said.

HPAs “are not necessarily people with extensive education and training–that's not the requirement,” Dr. Degutis said. “The requirement is more that they're familiar with the community, are interested in working with a range of people, are committed to working in the area of substance abuse, and have good interpersonal skills.”

Initially, HPAs screened all patients who were suspected of alcohol or drug use at the beginning of the program. After the program was more established, however, emergency practitioners screened some patients and sent them to the HPAs for brief interventions and referrals. HPAs still screen patients if they are not in the midst of taking care of patients who have been referred to them, said Dr. Degutis, associate professor of emergency medicine at the university.

The HPAs perform a brief, 10–15 minute intervention for anyone with a risky behavior and then refer to a variety of services in primary care, psychiatry, or social work. Alcohol use is gauged with the CAGE test and criteria from the National Institute on Alcohol Abuse and Alcoholism.

Of 22,923 patients screened for alcohol and other drug problems during December 1999 through December 2004, 10,255 (45%) reported using alcohol. Among the 5,243 patients who exceeded low-risk criteria set by the NIAAA, 43% (2,258) met the NIAAA criteria for at-risk or hazardous drinking or reported no more than one of the CAGE criteria. A total of 58% (3,085) were dependent on alcohol, based on meeting two or more CAGE criteria. About 15% of all the patients who were screened reported illicit drug use.

The HPAs performed brief interventions for 7,196 patients and referred 3,571 patients to specialized treatment facilities, mostly for problems with alcohol (59%), but also for drugs (28%) or both (13%).

At 1 month after presentation to the ED, the investigators were able to account for 74% of the referred patients either by talking with the patient directly on the phone or by calling the referred treatment facility. Of those who were contacted, 87% enrolled in a treatment program. Even if none of the patients who were not contacted enrolled in a treatment center, 64% of referred patients still enrolled in a treatment facility.

The Boston Medical Center ED, which originally started Project ASSERT as a demonstration project in 1993, runs a program similar to the one at Yale-New Haven. Several other hospitals around the country are trying to develop programs modeled after Project ASSERT.

One program is in its beginning stages at the Hospital of Saint Raphael, New Haven. So far the program has had some difficulty gaining support from ED staff at Saint Raphael, said Dr. Degutis. Unlike the HPAs at Yale-New Haven, the HPAs at Saint Raphael are not part of the ED staff. They are instead hired by the department of psychiatry at the hospital.

These HPAs have name badges with “psychiatry” printed on them, which “may change the way that the patient views them” when they go to ask a set of screening questions, Dr. Degutis explained. HPAs at Yale-New Haven have name badges printed with “Project ASSERT,” so that they can tell patients that they are part of a screening project to look for health risks.

BETHESDA, MD. – Personnel dedicated to screen, conduct brief interventions, and refer patients for alcohol and drug problems and other risky behaviors can make an important addition to the emergency department, according to investigators at Yale-New Haven Hospital.

In the Yale-New Haven (Conn.) program, called Project ASSERT, “health promotion advocates” (HPAs) relieve ED practitioners such as nurses, physicians, and physician assistants from conducting time-intensive visits with alcohol or drug abusing patients.

“It took people a little bit of time to get used to [the HPAs] and know that they were there, but once they saw what was happening where they were able to do these referrals and get patients out of the emergency department to a treatment facility, they saw it as beneficial,” said Linda C. Degutis, Dr.P.H., codirector of Project ASSERT (program for improving Alcohol and Substance Abuse Services and Educating Providers to Refer Patients to Treatment.)

Project ASSERT has received so much support from ED staff and the New Haven community that the hospital now completely funds the program outside of any grants, Dr. Gail D'Onofrio said at the annual conference of the Association for Medical Education and Research in Substance Abuse. Project ASSERT is funded by HPA consultation fees that are included in the hospital's billing processes.

The HPAs appear to have had a substantial impact on the patients they see. As many as 87% of the patients who were referred by the HPAs to specialized treatment centers for alcohol or other drug problems during 1999–2004 actually enrolled in treatment programs, said Dr. D'Onofrio, codirector of Project ASSERT.

Reports have shown that patients who present to the ED are more likely to have substance abuse problems than are those who present in a primary care setting, and less than 1% of ED patients with a diagnosis of substance abuse actually report it in the ED, said Dr. D'Onofrio, of the emergency medicine department at Yale University, New Haven.

In most EDs, practitioners do not routinely screen for drug and alcohol problems in patients who are not acutely intoxicated or do not ask for detox. “If someone comes in with an ankle sprain, [ED staff] are not asking them about alcohol and other drugs,” Dr. Degutis said in an interview. “That's where HPAs will do some screening and identify things that aren't generally identified by the staff.”

Time constraints prevent screening every patient who comes through the ED, but ED practitioners know that patients with certain diagnoses are more likely to have a problem, such as those with trauma.

The HPAs' duties include screening patients for at-risk alcohol and substance use or dependence, providing brief early interventions, and then referring ED patients to treatment programs. They also screen for selected health problems, domestic violence, and depression.

The program uses an equivalent of 2.8 full-time employees from 7 a.m. to 11 p.m. weekdays, 7 a.m. to 7 p.m. Saturdays, and 7 a.m. to 3:30 p.m. Sundays. So far, only one of the advocates is fluent in Spanish.

“It's important to know that when you try to do something like this in any place, it's really the people you hire, not particularly all your expertise” that makes the program work, Dr. D'Onofrio said at the conference, which also was sponsored by Brown Medical School. HPAs at Yale-New Haven came from jobs in occupational therapy, the department of public health, and addiction services, where they showed that they can relate well and are motivated to do that, she said.

HPAs “are not necessarily people with extensive education and training–that's not the requirement,” Dr. Degutis said. “The requirement is more that they're familiar with the community, are interested in working with a range of people, are committed to working in the area of substance abuse, and have good interpersonal skills.”

Initially, HPAs screened all patients who were suspected of alcohol or drug use at the beginning of the program. After the program was more established, however, emergency practitioners screened some patients and sent them to the HPAs for brief interventions and referrals. HPAs still screen patients if they are not in the midst of taking care of patients who have been referred to them, said Dr. Degutis, associate professor of emergency medicine at the university.

The HPAs perform a brief, 10–15 minute intervention for anyone with a risky behavior and then refer to a variety of services in primary care, psychiatry, or social work. Alcohol use is gauged with the CAGE test and criteria from the National Institute on Alcohol Abuse and Alcoholism.

Of 22,923 patients screened for alcohol and other drug problems during December 1999 through December 2004, 10,255 (45%) reported using alcohol. Among the 5,243 patients who exceeded low-risk criteria set by the NIAAA, 43% (2,258) met the NIAAA criteria for at-risk or hazardous drinking or reported no more than one of the CAGE criteria. A total of 58% (3,085) were dependent on alcohol, based on meeting two or more CAGE criteria. About 15% of all the patients who were screened reported illicit drug use.

The HPAs performed brief interventions for 7,196 patients and referred 3,571 patients to specialized treatment facilities, mostly for problems with alcohol (59%), but also for drugs (28%) or both (13%).

At 1 month after presentation to the ED, the investigators were able to account for 74% of the referred patients either by talking with the patient directly on the phone or by calling the referred treatment facility. Of those who were contacted, 87% enrolled in a treatment program. Even if none of the patients who were not contacted enrolled in a treatment center, 64% of referred patients still enrolled in a treatment facility.

The Boston Medical Center ED, which originally started Project ASSERT as a demonstration project in 1993, runs a program similar to the one at Yale-New Haven. Several other hospitals around the country are trying to develop programs modeled after Project ASSERT.

One program is in its beginning stages at the Hospital of Saint Raphael, New Haven. So far the program has had some difficulty gaining support from ED staff at Saint Raphael, said Dr. Degutis. Unlike the HPAs at Yale-New Haven, the HPAs at Saint Raphael are not part of the ED staff. They are instead hired by the department of psychiatry at the hospital.

These HPAs have name badges with “psychiatry” printed on them, which “may change the way that the patient views them” when they go to ask a set of screening questions, Dr. Degutis explained. HPAs at Yale-New Haven have name badges printed with “Project ASSERT,” so that they can tell patients that they are part of a screening project to look for health risks.