Improving the Hospital and Emergency Department Response to Substance Use Disorders

The challenge

Boston Medical Center (formerly Boston City Hospital) is the largest safety net hospital and busiest trauma and emergency services center in New England. In the early 1990s, when the nation was in the midst of the HIV/injection drug-use epidemic, patients came to the emergency department with complex needs related to their drug and alcohol misuse. This overwhelmed the care systems in place and led providers to seek new ways to meet the needs of these patients.

Edward Bernstein, M.D., emergency physician and then chairman of the Boston City Hospital ED’s quality improvement committee, began by looking at scientific literature and found two important avenues to explore for intervention: research by Morris Chafetz in the late 1950s at the Massachusetts General Hospital Accident Floor that demonstrated that psychiatry residents and social workers could team up successfully to engage middle-age, homeless, heavy-alcohol-consuming patients in treatment; and Bill Miller and Stephen Rollnick’s work on the efficacy of motivational interviewing.

In 1993, Edward Bernstein and Judith Bernstein, together with the Boston Public Health Commission and the Massachusetts Department of Public Health, submitted a “critical populations grant” application to the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment to improve the quality of care for the diverse patients struggling with substance use disorders who were coming to the Boston City Hospital ED. They were awarded a three-year grant that supported hiring a team of outreach workers, recruited from the communities served by the hospital, to work as part of the medical team to identify patients with substance misuse needs, intervene and offer resources. This was the beginning of Project ASSERT, which aims to improve alcohol and substance use disorder services, education and referral to treatment for ED patients.

Project ASSERT was the first nationally cited program in an ED to deploy peer counselors/educators as motivators and navigators to identify and intervene with patients with substance use disorders. The Project ASSERT team of outreach workers provided the “in-reach” that the ED staff needed to bridge the gap between what patients needed and the capacity to provide.

Getting to the root of the issue

The gap between those who need treatment for substance use disorders and those who seek and receive treatment contributed greatly to the problem of patients with substance use disorders returning through the “revolving door” of the ED.

In an ED, the goal of the clinical staff is to address immediate needs rapidly and then refer, which is often incompatible with the complex medical and social issues affecting patients with substance use disorders. The ED needed a program to motivate patients to seek out resources aimed at helping them overcome the individual and systemic barriers to accessible, effective treatment.

In addition, it was imperative that the hospital and its providers recognize and address the social determinants of the disease of addiction affecting their patients, including disparities, discrimination, unemployment, underemployment, inadequate education, homelessness, and traumatized individuals and families. People with substance use disorders also experience stigma in the form of social rejection and isolation in the health care system, which interferes with their seeking out and engaging in treatment. These issues, coupled with the need for more access to treatment, make recovery difficult, which can result in losses of opportunity, health and life.

The solution

In 1997, when the original Project ASSERT grant ended, Boston Medical Center demonstrated its commitment to the program by providing salary support for four full-time Health Promotion Advocates. Since that time, Project ASSERT has provided patient services from 8 a.m. to midnight daily, including holidays, operating under the direction of the social work department. Over the past 23 years, HPA consultations have improved communication between patients and providers and helped providers offer more informed, customized options for patients at discharge from the ED.

They have done this by:

• Bringing knowledge of community conditions and neighborhood life (the social determinants of health) to the emergency medicine practice.
• Serving as culture brokers by helping patients understand medical language and constructs while also helping medical professionals understand the complexity of patients’ lives, languages, priorities and choices.
• Consulting with providers during daily rounds and engaging patients in respectful, compassionate and informed conversations about their health and safety.
• Encouraging and motivating patients to seek help.
• Advocating for and facilitating access to an array of hospital and community resources and services.

In their interactions with patients, HPAs utilize the Brief Negotiated Interview algorithm developed at Boston Medical Center in 1994 in consultation with Rollnick. By addressing substance use disorders in the context of other health and safety needs, the team provides patients the opportunity to explore change through a nonjudgmental conversation and can facilitate access to a range of substance use disorder treatments and services.

As the opioid epidemic gathered steam in 2009, Project ASSERT collaborated with the South End Healthy Boston Coalition to train patients, family and friends in overdose recognition and appropriate responses, including calling 911 and initiating rescue breathing, and educate them about naloxone administration and rescue kit distribution. In 2014, BMC physicians began electronic ordering of naloxone rescue kits, which were distributed by ED pharmacists between midnight and 8 a.m.

Today, Project ASSERT staff includes a supervisor and six Massachusetts Licensed Alcohol and Drug Counselors. The program has evolved to provide consultation beyond the ED to inpatient and outpatient services. More recently, Project ASSERT collaborated with BMC’s Inpatient Addiction Consult Service and the Adult and Adolescent Office-Based Addiction Treatment Programs that offer medication therapies, such as buprenorphine and oral and injectable naltrexone to patients with substance use disorders. As a result of this collaboration, BMC was awarded a Massachusetts DPH grant for a Faster Paths to Treatment Regional Opioid Urgent Care Center program.

Faster Paths opened in August 2016 and has Project ASSERT counselors at its very core, conducting American Society of Addiction Medicine triage continuum provisional level of care evaluations and intake psychosocial assessments and negotiating treatment plans — all in addition to their work as motivators and navigators. Project ASSERT and Faster Paths now bring together independent silos of care into an expanded network and substance use disorder care delivery system that offers patients a broad spectrum of services, including medication therapy.

Choosing partners

Since its inception, Project ASSERT has partnered with:

• The Boston Public Health Commission, which has syringe exchange and naloxone distribution programs; inpatient and outpatient clinical stabilization, transitional and residential services; and the Providing Access to Addictions Treatment, Hope and Support Recovery Specialists program, which provides transportation and assistance to patients to get a Massachusetts Registry of Motor Vehicles ID so they can get their buprenorphine prescriptions filled, as well as access to an array of other services.
• Boston Health Care for the Homeless, which provides primary care and short-term respite, mental health services and a buprenorphine program while also providing access to shelters and housing-first programs.
• More than a dozen acute treatment or detox programs in Boston and its surrounding area.
• Methadone Maintenance Treatment/Methadone Maintenance providers and office-based addiction treatment in the primary care setting with X-waivered prescribers who prescribe buprenorphine/suboxone and naltrexone/vivitrol.
• The BMC system’s behavioral health clinic, programs for pregnant women, adolescents, adults and psychiatric patients, as well as community health centers and federally qualified health centers.
• Narcotics Anonymous and Alcoholics Anonymous, informally, through Project ASSERT’s staff contacts and community partners. 

Fruitful partnerships

Project ASSERT’s network of partners was built over many years of face-to-face contact with individuals and agencies that share common values of respectful, hospitable and quality services. Project ASSERT staff take personal responsibility for appropriate referrals and constantly elicit feedback from partners. Project ASSERT staff participate in joint staff meetings and community meetings, present at conferences, and exchange information, ideas and resources with colleagues. These ongoing collaborations have been helpful to address treatment gaps and to build sustainability. Some partnerships are informal, while others are detailed by memoranda of agreement and funding proposals. The Boston Public Health Commission’s recovery specialist, working with BMC under a Qualified Service Organization Agreement, documents provision of assessments, patient needs, treatment referrals and community support services in BMC’s electronic health record.

Reporting overdoses

If an overdose occurs in the Project ASSERT office, counselors call BMC’s rapid response team from the ED, and the hospital’s campus public safety officers and — when possible and necessary — Project ASSERT staff administer nasal naloxone/narcan. All Project ASSERT staff carry and are trained to administer naloxone and have been instrumental in saving lives. In the ED, Project ASSERT staff implement the PEERS protocol (page to bedside; evaluate; educate on overdose and distribute naloxone; referral to Faster Paths, detox or other service; safe discharge). The necessary forms are submitted to the Massachusetts Department of Public Health Bureau of Substance Abuse Services, which provides free naloxone rescue kits to patients.

Hospital support

Boston Medical Center offers financial support under the Faster Paths Opioid Urgent Care Center Grant. Project ASSERT also has a grant subcontract with the Boston Public Health Commission for its Recovery Specialist Community Support Services. In addition, BMC and Project ASSERT provide outside agencies and partners with consultation, medical evaluation for safe referrals and placement, and access to medical treatment and medication therapy for their clients.

Metrics for progress

Project ASSERT staff receive monthly reports from BMC’s data warehouse and analyze data from the project's electronic records. The Project ASSERT leadership supervisor and the medical director actively monitor the number of patients requesting detox or acute treatment as well as those denied and those refusing substance use disorder services. In addition, Faster Paths program grant leaders monitor the number of scheduled appointments and no-shows, the number of patients receiving intake assessments by an LADC, physician and nurse evaluations, prescriptions and transitions to maintenance office-based treatment, methadone maintenance treatment, or other programs. 

For more resources to help deal with the opioid crisis, see the American Hospital Association's toolkit.

Education to overcome stigma

Project ASSERT’s biggest challenge — and one of the biggest barriers to treatment of substance use disorders — has been stigma. Initially, there was a lack of understanding of substance use disorders and treatment options by patients, providers and the community. There was also a lack of capacity in the treatment system and barriers to access such as language, sexual identity, transportation, private insurance authorization, government ID requirements and bed availability.

Project ASSERT also experienced the challenges of integrating a peer model into the medical setting and the hierarchical culture of the ED as well as conflicts in collaborating across different departments and disciplines. To overcome the challenges related to stigma, undercapacity and resistance to collaboration, the Project ASSERT team patiently worked to build personal relationships with individuals in the network, and within and outside the hospital walls, to better serve patients. The services provided by Project ASSERT have contributed to patient and staff satisfaction. Project ASSERT staff play a strong role in advocacy at all levels of government and local agencies on behalf of BMC patients.

In the ED

Project ASSERT and the leaders within the ED made it a priority to invest in staff development and wellness with an emphasis on keeping on top of the latest treatment options and keeping an open mind to the needs and preferences of patients. Project ASSERT requires that staff be in compliance with Massachusetts DPH requirements and thus has provided continuing education opportunities and tuition reimbursement so that staff can meet their recertification requirements. Some examples of training topics have included motivational interviewing, maintaining patient confidentiality, boundaries and ethics, ASAM criteria, evidence-based addiction medication treatment, LGBTQ-appropriate services and respectful communications, cultural competence, trafficking, and military culture and substance use disorder services for those who have served our country.

Project ASSERT also sponsors an annual community tour for incoming emergency medicine residents to get to know the resources and resilience of the communities served by BMC’s ED.

Lessons learned

First and foremost, the Project ASSERT team learned that hospitality — a nonjudgmental, open-door, welcoming approach that promotes hope — was the most successful approach. The team learned the importance of genuine authenticity, and listening to and learning from patients as a means to building trust, which in turn yields more successful outcomes.

The team learned to listen carefully to clients about what is happening on the street, and to use this information to stay current and adapt Project ASSERT to address patient needs. To reduce stigma, Project ASSERT has changed the language the team uses and has stopped using language that was once common when treating patients with substance use disorders in an ED, such as “frequent flyer,” “addict,” “junkie,” “alcoholic,” “drunk” and “substance abuser.”

Project ASSERT recognized transportation as a major barrier to treatment access, and BMC’s development staff continue to raise funds to help defray the cost of transporting patients to treatment facilities.

Project ASSERT also received contributions from the information technology department, which built a robust electronic health record system and customized addiction templates to facilitate communications and continuity of care for better coordination. All patient information is entered into the EHR (Epic templates were designed by hospital IT staff), which includes demographics, the ASAM Triage Continuum to determine the provisional level of care, a full alcohol and drug and psycho-social assessment and documentation of placements, referrals made, and follow-up visits.

Project ASSERT could not have grown in volume and success over the course of 23 years without the full support of leadership at BMC and within the ED. In addition, the team could not provide an extensive menu of options to meet patients’ needs without ongoing collaboration with its treatment and community partners.

What would you do differently today?

While the Project ASSERT team has made significant progress, in hindsight there are things that could have provided additional support and benefits to patients and providers, including:

• Additional credentialing to increase the number of assessments and consultations.
• Offering more community support provider services available for BMC ED patients that are more hands-on after they leave the hospital setting, during transitions from the ED or hospital to community-based treatment and social services, and from the different levels of substance use disorder treatment back into the community. CSP services can address the social determinants of health and link patients to financial assistance, safe housing, job training and other services needed to incentivize and support recovery.
• Providing more ongoing education for emergency medicine physicians and nurses about the science of substance use disorders and the role they can play in opioid education, naloxone distribution and the evidence for initiating opioid treatment medication therapy within the ED.
• Implementing and monitoring physician and nursing quality-performance measures for substance use disorders in the same way that quality is measured for heart attacks, chest pain, pneumonia and sepsis.

Edward Bernstein, M.D., is founder and medical director of Project ASSERT. Ludy Young is a supervisor of Project ASSERT. Jenny Eriksen Leary is associate communications director of media relations at Boston Medical Center.

References

• Bernstein E., Bernstein J, Levenson S. "Project ASSERT: An ED-based intervention to increase access to primary care, preventive services and the substance abuse treatment system." Ann Emerg Med 1997; 30:181-189.

• Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., Hingson, R. (2005). "Brief Motivational intervention at a clinic visit reduces cocaine and heroin use." Drug Alc Depend. 77:49-59. (PMID: 15607841)

• Bernstein E, Shaw E, Topp D, Girard C, Pressman K, Woolcock S, Bernstein J. "A Preliminary report of knowledge translation: Lessons from taking screening and brief intervention techniques (SBI) from the research setting into regional systems of care." Acad Emerg Med 2009; 16:1225-1233.

• Van Boekel, L.C, et al. (2013). "Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review." Drug Alc Depend. 131: 23-35. (PMID: 23490450)

• Liebschutz, J.M. et al. (2014). "Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial." JAMA Intern Med. 174(8):1369-76. (PMID: 25090173)

• Dwyer, K., Walley, A.Y., Langlois, B.K., Mitchell, P.M., Nelson, K.P., Cromwell, J., Bernstein, E. (2015). "Opioid education and nasal naloxone rescue kits in the emergency department." West J Emerg Med. 16(3):381-4. (PMID: 25987910)

• D’Onofrio, G., O’Connor, P.G., Pantalon, M.V., Chawarski, M.C., Busch, S.H., Owens, P.H., Bernstein, S.L., Fiellin, D.A. (2015). "Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial." JAMA. 313(16):1636-1644. (PMID: 25919527)

• Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., Hingson, R. (2005). "Brief Motivational intervention at a clinic visit reduces cocaine and heroin use." Drug Alc Depend. 77:49-59. (PMID: 15607841)

• Drainoni, M.L., Koppelman, E.A., Feldman, J.A., Walley, A.Y., Mitchell, P.M., Ellison, J., Bernstein, E. "Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment." BMC Res Notes. 2016 Oct 18;9(1):465. PubMed PMID:27756427; PubMed Central PMCID: PMC5070095.

• Samuels E, Mello M, Baird J, Kellogg A, Bernstein E. "Emergency Department Opioid Harm Reduction: Assessing physician willingness." Acad Emerg Med. 2016 Apr;23(4):455-65. doi: 10.1111/acem.12910. Epub 2016 Mar 22.PubMed PMID: 26816030.

• Samuels, E.A., Hoppe, J., Papp, J., Whiteside, L., Raja, A.S., Bernstein, E. "Emergency Department Naloxone Distribution: Key Considerations and Implementation Strategies." American College of Emergency Physicians (Trauma and Injury Prevention Section White Paper) 2015. Available from http://www.acep.org/_Trauma-Section-Microsite/TIPS-White-Paper-PDF/

• SAMHSA’s National Registry of Evidence Based Programs and Practices: http://legacy.nreppadmin.net/ViewIntervention.aspx?id=222