Alcohol and drug use are associated with a variety of medical conditions[1, 2] and carry high global burdens of disease, injury, and cost[3, 4]. Substance use is associated with inadequate ambulatory care utilization and poor health outcomes, and people with substance use are over-represented among frequent consumers of emergency department (ED) and inpatient medical services. Substance abuse is predictive of discharge against medical advice, and inpatients discharged with substance use disorder (SUD) diagnoses, particularly drug-related diagnoses, have higher rates of recurrent ED and medical inpatient service utilization. This is not only associated with unnecessary human suffering but also generates disproportionately high health-care costs.
Hospital medical units are aggregators of people with SUDs, and hospitalization itself could serve as a “reachable moment” to intervene with these patients and engage them in appropriate SUD treatment after discharge. In-hospital interventions to help patients enter SUD treatment might improve this situation, and such programs are likely to receive heightened attention since the Patient Protection and Affordable Care Act will reduce Medicare payments to hospitals with excess readmissions beginning in October 2012.
In September 2008, leadership at Wilmington Hospital in the US state of Delaware collaborated with Brandywine Counseling and Community Services (BCCS), a major provider of SUD treatment in Delaware, to develop and implement Project Engage, a pilot program to identify medical and surgical inpatients with problematic substance use and to help them enter SUD treatment after discharge. Wilmington Hospital is a 241-bed general hospital owned and operated by Christiana Care Health System (CCHS), one of the largest health-care providers in the US mid-Atlantic region. Christiana Care Health System serves the state of Delaware and portions of seven New Jersey, Pennsylvania, and Maryland counties. In 2011, Wilmington Hospital recorded 52,178 ED visits and 13,778 medical and surgical admissions.
Project Engage has its theoretical basis in the literature on brief intervention (BI) to address excessive alcohol use among primary care outpatients; BI for risky drinking and alcohol dependence among medical inpatients[14, 15]; and screening, BI, and referral to treatment (SBIRT) for patients with moderate to high risk alcohol and/or drug use or dependence in diverse medical settings, including primary care, EDs, trauma centers, and inpatient and outpatient medical hospital services[16–18].
Studies reported in this literature have had promising outcomes. Patients in a large, federally funded SBIRT study conducted in six states reported decreases in illicit drug and heavy alcohol use subsequent to participation. Studies of SBIRT in EDs have demonstrated decreased health-care costs and inpatient utilization and increased rates of admissions to SUD treatment. Randomized trials of BI for excessive alcohol use among primary care outpatients have shown significant reductions in self-reported drinking. Data from screening and BI (SBI) for primary care outpatients with unhealthy nondependent alcohol use led the US Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to include performance measures for its use in hospitals.
Although these lines of research are significant, they have important gaps. For example, most published studies have applied BI to patients with unhealthy or risky drinking, alcohol abuse, and/or alcohol dependence. In reality, alcohol and drug problems are frequently comorbid, and patients with alcohol and drug problems—or primary drug problems—are also in need of care. Further, the majority of BI studies demonstrated efficacy in reducing alcohol use when alcohol-dependent individuals were excluded[21, 22]; however, patients with alcohol dependence constitute the majority of medical inpatients with alcohol problems and have a great need for SUD treatment. A literature search revealed a paucity of published studies of alcohol and drug BI or SBIRT conducted exclusively with hospital inpatients. Finally, hospitalized patients with SUDs often face multiple barriers to accessing treatment including homelessness, brief lengths of stay complicating discharge planning, ambivalence, and inadequate transfer resources. These problems require an increased emphasis on referral to treatment. Since the chances of engaging patients in treatment decrease with the length of time between assessment and treatment admission, facilitated admission could be particularly important for this population.
Description of the project engage pilot program
In many cases, SUDs directly or indirectly contribute to health problems leading to hospitalization. Patients with SUDs are often well known to hospital staff, but clinical teams typically have little training or experience in addressing SUDs. In fact, hospital personnel are often frustrated with these patients due to frequent rehospitalizations, noncompliance with recommendations to cut back or abstain, and resistance to entering and staying in SUD treatment. Project Engage, a modified version of BI and SBIRT, was designed to provide bedside assistance for the clinical team to address these problems. It consists of SUD identification by hospital staff based on clinical impressions but without a universal standardized screening process to identify alcohol and drug problems, followed by BI and facilitated referral to treatment (FRT). Although there are efforts to identify patients, this does not constitute “screening” because a universal, standardized approach to identification is not employed. Referral to treatment is enhanced by facilitation. The Project Engage pilot program described here was not designed as a research study, although self-report data on initiation of SUD treatment by Project Engage patients after discharge were collected, and insurance-claims data on two small cohorts of patients were examined retrospectively.
Hospital clinical staff identified patients with possible alcohol and/or drug problems per usual procedures. Before Project Engage was initiated, brief trainings were provided to nursing staff on how to identify patients with problematic drug or alcohol use. The potential value of connecting them to treatment was emphasized, and an overview of the Project Engage program along with contact information for Project Engage staff was provided. In October 2009, the Alcohol Use Disorders Identification Test-Primary Care (AUDIT-PC)[26–28], a five-item self-report instrument to detect “hazardous and harmful alcohol consumption,” was initiated system-wide at CCHS to detect patients at risk for alcohol withdrawal and delirium tremens (DTs), and nursing staff administered it to all medical/surgical inpatients at admission.
Patients were identified for possible inclusion in Project Engage if they met any of the following criteria: clinical suspicion of alcohol and/or drug abuse or dependence; hospital admission likely related to alcohol and/or drug abuse or dependence; positive result on a drug test; AUDIT-PC ≥ 5 (as of October 2009); primary, secondary, or tertiary diagnosis related to substance use; or self-reported past or current alcohol and/or drug use. Patients under age 18 or with senility, dementia, or other disorders that interfered with the ability to provide informed consent to be seen by a non-CCHS provider were excluded from Project Engage. Nursing staff provided eligible patients with a choice to participate—or not participate—in Project Engage. Although Project Engage was not a research study, patients who chose to participate in it signed a “Choice Form” as part of an informed-consent process required in order to be seen by a non-CCHS provider. (The patient engagement specialists [PESs] were employed by BCCS.) Unfortunately, the number of patients who were identified and approached for participation, the number of interventions received by each patient, and the number of Project Engage patients who were unwilling to accept a referral were not recorded.
Patients who chose to participate in Project Engage received a BI from a PES hired specifically for the project. Project Engage specialists were in stable recovery from alcohol and/or drugs (at least two years without drug or alcohol use) and selected on the basis of emotional stability, experience in recovery, and interpersonal strengths. They received training in working in a health-care setting, co-occurring disorders, rapport building, basic interviewing techniques, assessment, motivational interviewing (MI), treatment referral, and ethics and were regularly supervised by licensed chemical-dependency professionals.
The BI occurred while patients were hospitalized and consisted of rapport building, a brief assessment, and one or two brief motivational interviewing (MI) sessions to enhance patient motivation to attend SUD treatment and accept a facilitated referral. The purpose of the assessment was to determine if patients might benefit from SUD treatment and to identify possible barriers to transitioning them into it. The PESs used the Delaware Division of Substance Abuse and Mental Health (DSAMH) Co-Occurring Conditions Screening Instrument in conjunction with information gathered during MI sessions and the DSAMH/American Society of Addiction Medicine (ASAM) Crosswalk to match patient treatment needs to treatment programs according to ASAM’s Patient Placement Criteria-2nd Revision (ASAM PPC-2R). If treatment slots in appropriate Delaware programs were not available, patients received facilitated referrals to programs in neighboring states.
Facilitated referral to treatment
When patients were willing to consider SUD treatment, the PESs provided them with facilitated referrals as follows: They discussed potential treatment programs, and when patients agreed to consider a program, the PESs determined whether that program had an opening, whether it accepted the patient’s insurance or could admit him/her with other funding, and (if both these conditions were met) made an appointment for a time that was convenient to the patient. Patients who were in need of treatment and willing to accept a referral received a date and time for an appointment or inpatient admission rather than the name and phone number of a program. For programs that required the Addiction Severity Index, PESs administered it at bedside if patients were willing to complete it. The PESs also assessed potential barriers to treatment initiation such as homelessness, transportation difficulties, or lack of appropriate clothing. When necessary, patients were given bus or train tickets, driven to the treatment program, or picked up by the treatment program upon discharge. The PESs also contacted shelters for housing, acquired clothing for patients in need, and called patients within 48 hours after their scheduled admission or appointment to confirm that they attended. When patients reported having gone to treatment, PESs gave positive feedback and encouraged them to continue; when patients reported that they had not gone to treatment, PESs attempted to problem-solve any barriers and left the door open for future contact to facilitate admissions or appointments.