Before Kevin M.'s drinking problem began, before he became what he calls a "frequent flyer" in the Yale New Haven Hospital emergency department (ED), he was a policeman in Hollywood, Florida. There, he became involved in several shooting incidents. Though a civilian review board determined he had been justified, he says, he was asked to "leave the department quietly."
Next, Kevin became a successful salesman of automatic doors. Even as his business thrived and he found himself in demand as an expert witness in automatic-door liability cases, he began to drink alone in hotels.
Then a $50 million lawsuit hit. It ruined his finances as well as his marriage.
"That's when my alcoholism really started to flourish," says Kevin, now a 64-year-old retiree living in New Haven. "I came back up north, broke, enraged, and just kept drinking and drinking. My whole family didn't want me around." Often homeless, hospitalized, or in jail, Kevin spent over seven years in and out of the Yale ED. And it was in the ED that Kevin connected with Project ASSERT—and turned his life around.
The project's deceptively simple mission: to screen patients for substance use disorders, conduct a brief negotiation interview, and refer patients to treatment (a trio of actions abbreviated to SBIRT). It staffs the EDs of both Yale New Haven Hospital (YNHH) and the Saint Raphael campus with Health Promotion Advocates (HPAs) trained to conduct the short interviews, which help patients explore the pros and cons of substance use, and begin to think about the possibility of change. For those who feel ready, project staff can arrange for transfers to detox or rehab directly from the ED. Since the program's founding, it has arranged treatment for some 48,000 people. "We are their voice in the ED," says HPA Shevonne Mack.
In 2016, of all the patients the HPAs met with in the ED, 22 percent went straight into treatment, while another 43 percent received treatment referrals. Getting people the substance abuse treatment they need is not only good patient care and good public health, resulting in fewer ED visits due to injury, it may also be good economics. One 2005 study found that an ED-based program saved $3.81 for every $1.00 it spent on an SBIRT program.
Gregory Johnson is a founding member of Project ASSERT and one of several HPAs who worked with Kevin. Johnson attributes the project's successes to its home base in the ED. Accosting people with substance use disorders on the street may or may not lead anywhere—it's all too easy to toss an informational flyer, for instance. But an ED visit can bring long waits and time for reflection—the perfect opportunity for a caring outsider to offer help.
"If the patient recognizes that he has arrived at the chest pain center because of cocaine and alcohol use and I tell them 'I can get you directly into treatment from the ED, from point A to point B', they're more likely to say, 'Let's go for it,' " Johnson says.
The project began in 1999 as a one-year, grant-funded initiative to help people with substance problems self-reflect via the brief negotiation interview. Within a few months, its mission grew, according to Johnson. Not only were HPAs finding at-risk drinking and drug use, they were uncovering severe substance use disorders.
The normal procedure in such cases was to alert social workers, who would refer patients for treatment. But social workers often did not show up in the ED when called, Johnson says. So he took matters into his own hands. Having previously worked at New Haven's South Central Rehabilitation Center, he knew how to get people into treatment, and he started doing so. After the grant ran out, the hospital hired the team as permanent employees.
"We became the substance treatment people," Johnson says.
In addition to short detox programs for the physically addicted, HPAs also arrange longer stays in rehab. Project ASSERT also emphasizes harm reduction, offering naloxone antidote kits, suboxone, and methadone clinic appointments for some patients.
The idea of bringing public health initiatives like this to the ED is partly that of Gail D'Onofrio, M.D., M.S., the chief of Emergency Services. D'Onofrio is a renowned federally funded SBIRT expert who sees to it that all primary-care resident physicians at Yale learn the technique.
The HPAs credit much of their success to personal connections—among the community as well as to the patients they serve. Being on a first-name basis with rehab and detox workers all over the state can often open doors, for instance, especially for patients whose insurance doesn't cover treatment or who lack it altogether. And, recognizing patients' difficult life circumstances, which can make relapse hard to avoid, the team also works to connect them to other area resources wherever possible.
That personal connection with patients can be especially important after relapse. Those who decide to try again often ask for help from an HPA they've come to trust.
"I've had patients who call their mother and their mother hangs up on them because they burned so many bridges," Johnson says. "If I say I can provide immediate help for them, and I actually come through on my word, that leaves an imprint on them."
For Kevin, an HPA's words at a crucial moment made all the difference. One morning, he went to Yale New Haven Hospital to collect belongings he'd left during a discharge the previous day. He planned to hit the liquor store next. But as he waited in the hospital atrium, one of the HPAs spotted him and came to say hello. She asked him if he'd been drinking that morning. He had.
"She sat and talked to me," he recalls. "Something went on in my head that said, 'Are you ready to stop?' "
Kevin walked to the ED, where his blood pressure and heart rate were found to be sky-high. That morning's drink turned out to be his last. After his discharge, he became deeply involved with Alcoholics Anonymous. No longer homeless, he spends up to four days a week at Yale New Haven Hospital and the Saint Raphael campus, talking with others who struggle with alcoholism.
"I try to give them what was given to me, which is that little light in your head that's in that very dark place that says, 'You don't have to live this way anymore,' " Kevin says. "That's what the folks over at the ER with the project over there do. … They never gave up on me."
"You can't be judgmental, and you've got to be compassionate, and you've got to understand it's a disease," says HPA Damaris Navarro. "They come back, they're going to come back, but that's a part of getting better."
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