Early data from Project Engage: a program to identify and transition medically hospitalized patients into addictions treatment

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BACKGROUND: Patients with untreated substance use disorders (SUDs) are at risk for frequent emergency department visits and repeated hospitalizations. Project Engage, a US pilot program at Wilmington Hospital in Delaware, was conducted to facilitate
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  RESEARCH Open Access Early data from project engage: a program toidentify and transition medically hospitalizedpatients into addictions treatment Anna Pecoraro 1,2 , Terry Horton 2,3* , Edward Ewen 3 , Julie Becher 1 , Patricia A Wright 4 , Basha Silverman 5,6 ,Patty McGraw 3 and George E Woody 1,2 Abstract Background:  Patients with untreated substance use disorders (SUDs) are at risk for frequent emergencydepartment visits and repeated hospitalizations. Project Engage, a US pilot program at Wilmington Hospital inDelaware, was conducted to facilitate entry of these patients to SUD treatment after discharge. Patients identifiedas having hazardous or harmful alcohol consumption based on results of the Alcohol Use Disorders Identification Test-Primary Care (AUDIT-PC), administered to all patients at admission, received bedside assessment withmotivational interviewing and facilitated referral to treatment by a patient engagement specialist (PES). Thisprogram evaluation provides descriptive information on self-reported rates of SUD treatment initiation of allpatients and health-care utilization and costs for a subset of patients. Methods:  Program-level data on treatment entry after discharge were examined retrospectively. Insurance claimsdata for two small cohorts who entered treatment after discharge (2009, n=18, and 2010, n=25) were reviewedover a six-month period in 2009 (three months pre- and post-Project Engage), or over a 12-month period in 2010(six months pre- and post-Project Engage). These data provided descriptive information on health-care utilizationand costs. (Data on those who participated in Project Engage but did not enter treatment were unavailable). Results:  Between September 1, 2008, and December 30, 2010, 415 patients participated in Project Engage, and 180(43%) were admitted for SUD treatment. For a small cohort who participated between June 1, 2009, and November30, 2009 (n=18), insurance claims demonstrated a 33% ($35,938) decrease in inpatient medical admissions, a 38%($4,248) decrease in emergency department visits, a 42% ($1,579) increase in behavioral health/substance abuse(BH/SA) inpatient admissions, and a 33% ($847) increase in outpatient BH/SA admissions, for an overall decrease of $37,760. For a small cohort who participated between June 1, 2010, and November 30, 2010 (n=25), claimsdemonstrated a 58% ($68,422) decrease in inpatient medical admissions; a 13% ($3,308) decrease in emergencydepartment visits; a 32% ($18,119) decrease in BH/SA inpatient admissions, and a 32% ($963) increase in outpatientBH/SA admissions, for an overall decrease of $88,886. (Continued on next page) * Correspondence: THorton@christianacare.org 2 Clinical Trials Network, Delaware Valley Node, Wilmington, DE, USA 3 Christiana Care Health System and Wilmington Hospital, Wilmington, DE,USAFull list of author information is available at the end of the article © 2012 Pecoraro et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the srcinal work is properly cited. Pecoraro  et al. Addiction Science & Clinical Practice  2012,  7 :20http://www.ascpjournal.org/content/7/1/20  (Continued from previous page) Conclusions:  These findings demonstrate that a large percentage of patients entered SUD treatment afterparticipating in Project Engage, a novel intervention with facilitated referral to treatment. Although the findings arelimited by the retrospective nature of the data and the small sample sizes, they do suggest a potentiallycost-effective addition to existing hospital services if replicated in prospective studies with larger samples andcontrols. Keywords:  Addiction, Drug, Alcohol, Hospital, Medical patients, Brief intervention, Facilitated referral to treatment,SBIRT, BI, Treatment initiation Background 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 asso- ciated with inadequate ambulatory care utilization andpoor health outcomes [5], and people with substance useare over-represented among frequent consumers of emergency department (ED) [6] and inpatient [7] me- dical services. Substance abuse is predictive of dischargeagainst medical advice [8], and inpatients dischargedwith substance use disorder (SUD) diagnoses, particu-larly drug-related diagnoses, have higher rates of recur-rent ED and medical inpatient service utilization [9].This is not only associated with unnecessary human suf-fering but also generates disproportionately high health-care costs [10].Hospital medical units are aggregators of people withSUDs, and hospitalization itself could serve as a  “ reach-able moment ”  to intervene with these patients and en-gage them in appropriate SUD treatment after discharge[11]. In-hospital interventions to help patients enterSUD treatment might improve this situation, and suchprograms are likely to receive heightened attention sincethe Patient Protection and Affordable Care Act [12] willreduce Medicare payments to hospitals with excess read-missions beginning in October 2012.In September 2008, leadership at Wilmington Hospitalin the US state of Delaware collaborated with Brandy-wine Counseling and Community Services (BCCS), amajor provider of SUD treatment in Delaware, to de- velop and implement Project Engage, a pilot program toidentify medical and surgical inpatients with problematicsubstance use and to help them enter SUD treatmentafter discharge. Wilmington Hospital is a 241-bed ge-neral hospital owned and operated by Christiana CareHealth System (CCHS), one of the largest health-careproviders in the US mid-Atlantic region. Christiana CareHealth System serves the state of Delaware and portionsof seven New Jersey, Pennsylvania, and Maryland coun-ties. In 2011, Wilmington Hospital recorded 52,178 ED visits and 13,778 medical and surgical admissions.Project Engage has its theoretical basis in the literatureon brief intervention (BI) to address excessive alcoholuse among primary care outpatients [13]; BI for risky drinking and alcohol dependence among medical inpati-ents [14,15]; and screening, BI, and referral to treat- ment (SBIRT) for patients with moderate to high riskalcohol and/or drug use or dependence in diverse me-dical settings, including primary care, EDs, trauma cen-ters, and inpatient and outpatient medical hospitalservices [16-18]. Studies reported in this literature have had promisingoutcomes. Patients in a large, federally funded SBIRTstudy conducted in six states reported decreases in illicitdrug and heavy alcohol use subsequent to participation[16]. Studies of SBIRT in EDs have demonstrateddecreased health-care costs and inpatient utilization [17]and increased rates of admissions to SUD treatment[19]. Randomized trials of BI for excessive alcohol useamong primary care outpatients [13] have shown signifi-cant reductions in self-reported drinking. Data fromscreening and BI (SBI) for primary care outpatients withunhealthy nondependent alcohol use [13] led the USJoint Commission on Accreditation of Healthcare Orga-nizations (JCAHO) to include performance measures forits use in hospitals [20].Although these lines of research are significant, they have important gaps. For example, most published stu-dies have applied BI to patients with unhealthy or risky drinking, alcohol abuse, and/or alcohol dependence. Inreality, alcohol and drug problems are frequently comor-bid, and patients with alcohol and drug problems — orprimary drug problems — are also in need of care. Fur-ther, the majority of BI studies demonstrated efficacy inreducing alcohol use when alcohol-dependent indivi-duals were excluded [21,22]; however, patients with alco- hol dependence constitute the majority of medicalinpatients with alcohol problems [23] and have a greatneed for SUD treatment. A literature search revealed apaucity of published studies of alcohol and drug BI orSBIRT conducted exclusively with hospital inpatients. Fi-nally, hospitalized patients with SUDs often face mul-tiple barriers to accessing treatment includinghomelessness, brief lengths of stay complicating dis-charge planning, ambivalence, and inadequate transferresources [24]. These problems require an increased Pecoraro  et al. Addiction Science & Clinical Practice  2012,  7 :20 Page 2 of 7http://www.ascpjournal.org/content/7/1/20  emphasis on referral to treatment. Since the chances of engaging patients in treatment decrease with the lengthof time between assessment and treatment admission[25], facilitated admission could be particularly importantfor this population. Description of the project engage pilot program In many cases, SUDs directly or indirectly contribute tohealth problems leading to hospitalization. Patients withSUDs are often well known to hospital staff, but clinicalteams typically have little training or experience inaddressing SUDs. In fact, hospital personnel are oftenfrustrated with these patients due to frequent rehospita-lizations, noncompliance with recommendations to cutback or abstain, and resistance to entering and staying inSUD treatment. Project Engage, a modified version of BIand SBIRT, was designed to provide bedside assistancefor the clinical team to address these problems. It con-sists of SUD identification by hospital staff based onclinical impressions but without a universal standardizedscreening 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. TheProject Engage pilot program described here was notdesigned as a research study, although self-report dataon initiation of SUD treatment by Project Engagepatients after discharge were collected, and insurance-claims data on two small cohorts of patients were exam-ined retrospectively. Identification Hospital clinical staff identified patients with possible alco-hol and/or drug problems per usual procedures. BeforeProject Engage was initiated, brief trainings were providedto nursing staff on how to identify patients with problem-atic drug or alcohol use. The potential value of connectingthem to treatment was emphasized, and an overview of the Project Engage program along with contact informa-tion for Project Engage staff was provided. In October2009, the Alcohol Use Disorders Identification Test-Primary Care (AUDIT-PC) [26-28], a five-item self-report instrument to detect  “ hazardous and harmful alcohol con-sumption [29], ”  was initiated system-wide at CCHS to de-tect patients at risk for alcohol withdrawal and deliriumtremens (DTs), and nursing staff administered it to allmedical/surgical inpatients at admission.Patients were identified for possible inclusion in ProjectEngage if they met any of the following criteria: clinicalsuspicion of alcohol and/or drug abuse or dependence;hospital admission likely related to alcohol and/or drugabuse 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. Patientsunder age 18 or with senility, dementia, or other disordersthat interfered with the ability to provide informed con-sent to be seen by a non-CCHS provider were excludedfrom Project Engage. Nursing staff provided eligiblepatients with a choice to participate — or not participate — in Project Engage. Although Project Engage was not a re-search study, patients who chose to participate in it signeda  “ Choice Form ”  as part of an informed-consent processrequired in order to be seen by a non-CCHS provider.(The patient engagement specialists [PESs] were employedby BCCS.) Unfortunately, the number of patients whowere identified and approached for participation, thenumber of interventions received by each patient, and thenumber of Project Engage patients who were unwilling toaccept a referral were not recorded. Brief intervention Patients who chose to participate in Project Engagereceived a BI from a PES hired specifically for the pro- ject. Project Engage specialists were in stable recovery from alcohol and/or drugs (at least two years withoutdrug or alcohol use) and selected on the basis of emo-tional stability, experience in recovery, and interpersonalstrengths. They received training in working in a health-care setting, co-occurring disorders, rapport building,basic interviewing techniques, assessment, motivationalinterviewing (MI), treatment referral, and ethics and wereregularly supervised by licensed chemical-dependency professionals.The BI occurred while patients were hospitalized andconsisted of rapport building, a brief assessment, andone or two brief motivational interviewing (MI) sessions[30] to enhance patient motivation to attend SUD treat-ment and accept a facilitated referral. The purpose of the assessment was to determine if patients might bene-fit from SUD treatment and to identify possible barriersto transitioning them into it. The PESs used the Dela-ware Division of Substance Abuse and Mental Health(DSAMH) Co-Occurring Conditions Screening Instru-ment in conjunction with information gathered duringMI sessions and the DSAMH/American Society of Ad-diction Medicine (ASAM) Crosswalk to match patienttreatment needs to treatment programs according toASAM ’ s Patient Placement Criteria-2nd Revision(ASAM PPC-2R [31]). If treatment slots in appropriateDelaware programs were not available, patients receivedfacilitated 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 Pecoraro  et al. Addiction Science & Clinical Practice  2012,  7 :20 Page 3 of 7http://www.ascpjournal.org/content/7/1/20  follows: They discussed potential treatment programs,and when patients agreed to consider a program, thePESs determined whether that program had an open-ing, whether it accepted the patient ’ s insurance orcould admit him/her with other funding, and (if boththese conditions were met) made an appointment fora time that was convenient to the patient. Patientswho were in need of treatment and willing to accepta referral received a date and time for an appoint-ment or inpatient admission rather than the nameand phone number of a program. For programs thatrequired the Addiction Severity Index [32], PESsadministered it at bedside if patients were willing tocomplete it. The PESs also assessed potential barriersto treatment initiation such as homelessness, transpor-tation difficulties, or lack of appropriate clothing.When necessary, patients were given bus or train tick-ets, driven to the treatment program, or picked up by the treatment program upon discharge. The PESs alsocontacted shelters for housing, acquired clothing forpatients in need, and called patients within 48 hoursafter their scheduled admission or appointment toconfirm that they attended. When patients reportedhaving gone to treatment, PESs gave positive feedbackand encouraged them to continue; when patientsreported that they had not gone to treatment, PESsattempted to problem-solve any barriers and left thedoor open for future contact to facilitate admissionsor appointments. Methods The Project Engage pilot at Wilmington Hospital wasnot prospectively designed as a research study; however,program-level data on patients ’  self-reported initiation of SUD treatment, as well as a description of health-careutilization before and after the intervention for twosmall cohorts of Project Engage patients who enteredSUD treatment, were available from a single health planand are presented here. Participants Participants included all Project Engage patients seenbetween 9/1/2008 and 12/30/2010 (n=415) as well astwo smaller groups of patients who received the ProjectEngage intervention, initiated SUD treatment after dis-charge, and had uninterrupted insurance coverage andcomplete claims data three months before and threemonths after the intervention (2009 group) (n=18) orsix months before and six months after the intervention(2010 group) (n=25).Of the 415 patients seen between September 1, 2008,and December 30, 2010, 275 (65%) were male, and 135(33%) were female (5 did not self-identify as either gen-der); 201 (48%) were white, 188 (45%) were black, and26 (6%) self-identified as mixed race or other. The ave-rage age of patients was 46 years (SD, 11.8 years), and183 (44%) were  ≥ 50 years. Regarding their primary sub-stance of choice (some were multiple), 240 (58%)reported alcohol, 90 (22%) reported crack or powder co-caine, 64 (15%) reported heroin, 17 (4%) reportedmarijuana, 11 (3%) reported an opioid other than heroin,5 (0.01%) reported benzodiazepines, and 4 (0.01%)reported methamphetamines.The two smaller cohorts consisted of all patientsinsured by Delaware Physicians Care Incorporated(DPCI) who had uninterrupted coverage and completeclaims data. The 2009 cohort participated in Project En-gage between June 1, 2009, and November 30, 2009, andconsisted of nine men and nine women. The averageage was 43 years (SD, 10 years). The 2010 cohort par-ticipated in Project Engage between June 1, 2010, andNovember 30, 2010, and consisted of 12 men and 13women. The average age was 40 years (SD, 12 years).Unfortunately, the small number of patients meetinginclusion criteria (uninterrupted coverage and completeclaims data) did not allow for random selection. Data analytic strategy Brandywine Counseling and Community Services fur-nished program-level data on the number of patientswho participated in Project Engage between September1, 2008, and December 30, 2010, and on self-reportedSUD treatment initiation after discharge. Delaware Phy-sicians Care Incorporated provided claims data for twosmaller cohorts. Christiana Care Health System ’ s Institu-tional Review Board approved queries to BCCS ’ s ProjectEngage records to determine rates of treatment initiationand the use of data from DPCI ’ s reports for a posterpresentation [33] and this article. Unfortunately, theDPCI datasets from which the reports were generatedwere not available to the authors, so detailed health eco-nomic analyses were not possible. Results Program-level data: Participant admissions to SUDtreatment Between September 1, 2008, and December 30, 2010,415 patients participated in Project Engage. (The num-ber of patients identified and approached for participa-tion was not recorded.) Of these patients, 180 (43%)were admitted to an inpatient treatment program and/orattended one or more session(s) at an outpatient pro-gram. Of these patients, 16 (8%) were admitted to in-patient detoxification; 53 (29%) were admitted toresidential treatment; 103 (57%) were admitted to out-patient treatment; and 8 (4%) were admitted to transi-tional housing and treatment (Table 1). Pecoraro  et al. Addiction Science & Clinical Practice  2012,  7 :20 Page 4 of 7http://www.ascpjournal.org/content/7/1/20  Cohort-level data: Health-care utilization and costs beforeand after participation in project engage Delaware Physicians Care Incorporated provided health-care utilization and costs for inpatient medical admissions,ED visits, and inpatient and outpatient behavioral health/substance abuse (BH/SA) admissions before and after the2009 and 2010 subgroups received the Project Engageintervention (DPCI was not able to differentiate be-tween BH and SA treatment in reported outcomes). Thehospitalization during which patients received the ProjectEngage intervention was not included in these costs, butSUD treatment costs after hospitalization were included.Of the 18 patients in 2009 subgroup who initiatedSUD treatment after discharge, five had at least one BH/SA outpatient visit subsequent to the Project Engageintervention, and six had at least one inpatient BH/SAadmission. There was a 33% ($35,938) decrease in in-patient medical admissions in this subgroup, a 38%($4,248) decrease in ED visits, a 42% ($1,579) increase inBH/SA inpatient admissions, and a 33% ($847) increasein outpatient BH/SA admissions, for an overall cost de-crease of $37,760 (Table 2).Of the 25 patients in the 2010 subgroup who initiatedSUD treatment after discharge, 13 had at least one BH/SA outpatient visit subsequent to the Project Engageintervention, and 9 had at least one inpatient BH/SA ad-mission. a 58% ($68,422) decrease in inpatient medicaladmissions; a 13% ($3,308) decrease in emergency department visits; a 32% ($18,119) decrease in BH/SAinpatient admissions, and a 32% ($963) increase in out-patient BH/SA admissions, for an overall decrease of $88,886 (Table 2). Discussion Although this pilot program was not designed as a re-search study, retrospective evaluation of the data yieldeduseful descriptive information. Project Engage involvedcollaboration between a large hospital system, an SUDtreatment provider, and a health plan and demonstratedthat such collaboration is possible in a clinical setting. Italso demonstrated that cost data (although limited) canbe obtained outside the context of a formal researchstudy. Importantly, FRT (a major component of ProjectEngage) is an innovative approach that warrants furtherstudy to assess its impact on treatment enrollment. Theuse of PESs rather than graduate students or licensedclinicians differs from approaches common in the exist-ing BI and SBIRT literature. The success of Project En-gage suggests interventions delivered by such individualsare accepted by patients and could be used in these andother settings.The finding that a relatively large proportion (43%) of Project Engage patients entered SUD treatment after dis-charge is promising. Krupski et al. [19] examined admis-sions to treatment subsequent to BI (MI without referralto treatment) in ED patients who screened positive foralcohol and/or other drug problems and found that 34%of those who received the intervention were admitted toSUD treatment within 12 months compared with 23% of those who did not receive it. Saitz et al. [14] studied a BI(single MI session without referral to treatment) formedical inpatients with risky drinking or alcohol de-pendence and found that, among alcohol-dependentpatients, 49% of the MI group and 44% of the controlgroup attended alcohol treatment within three months;between-group differences were not significant. Our Table 1 Admissions to substance abuse treatment forproject engage patients seen between September 1,2008, and December 30, 2010 (N=415) Admitted to a Substance Abuse Treatment Program 180 (43%)- Inpatient Detoxification 16/180 (8%)- Residential Treatment 53/180 (29%)- Outpatient 103/180 (57%)- Transitional Housing and Outpatient 8/180 (4%) Table 2 Health care utilization among patients in the 2009 and 2010 project engage subgroups Subgroup (N=18)Pre-Intervention (n) Post-Intervention (n) Difference Inpatient Medical Admissions 12 8 33% decrease ($35,938)Emergency Department Visits 54 33 38% decrease ($4,248)Inpatient Behavioral Health/Substance Abuse Admissions 7 10 42% increase ($1,579)Outpatient Behavioral Health/Substance Abuse Admissions 12 16 33% increase ($847) 2010 Subgroup (N=25)Pre-Intervention (n) Post-Intervention (n) Difference Inpatient Medical Admissions 17 7 58% decrease ($68,422)Emergency Room Visits 133 116 12.7% decrease ($3,308)Inpatient Behavioral Health/Substance Abuse Admissions 28 19 32% decrease ($18,119)Outpatient Behavioral Health/Substance Abuse Admissions 25 33 32% increase ($963) Pecoraro  et al. Addiction Science & Clinical Practice  2012,  7 :20 Page 5 of 7http://www.ascpjournal.org/content/7/1/20
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