A frail, 67-year-old woman came into the ,Emergency Department at Yale-New Haven Hospital one evening last fall complaining about terrible abdominal pain.
The medical staff immediately began to search for its cause and sought to ease her misery. As the emergency medical procedures went on, Gregory Johnson, a health promotion advocate from Project ASSERT, an innovative Yale health outreach program, approached her bedside and asked her a few questions. Her answers shocked the medical staff and probably saved the woman's life.
The grandmotherly woman revealed that she was a heroin addict, shooting up the drug several times a day. While the medical staff helped relieve her abdominal pain, Johnson took advantage of the woman's health crisis to help negotiate with her about entering into treatment for her addiction. She agreed, and he arranged for her admission to an area substance abuse program. He even found her transportation to the site and followed up later to make sure she stuck to her program.
"Doctors are busy treating acute medical problems," says Johnson. "They're not thinking about a whole other realm of treatment. If I hadn't intervened, we never would have known."
Johnson is one of the three health promotion advocates under the direction of Dr. Gail D'Onofrio and Linda Degutis, associate professors of surgery in the School of Medicine's Section of Emergency Medicine, who founded Project ASSERT.
The pioneering program uses the Emergency Department at the hospital as a means of identifying patients who abuse alcohol and drugs or engage in other high risk behaviors, and -- when possible -- intervening to help the patients get the attention they need. D'Onofrio and her staff provide patient education and, where necessary, referral for substance abuse treatment, primary care and other preventive services. The Project ASSERT team works with over a score of public and private programs around the region.
Standing at the control desk in the Emergency Department on a recent winter afternoon, Project ASSERT health promotion advocate Ralph Soldano gestured at the surrounding hustle and uproar as dozens of patients waited for care. "When people come here," he says, "they are often at rock bottom. If you can make the link from here in a timely way, they're more likely to go into treatment." Sometimes it takes direct action. "We'll literally walk them to facilities if we have to," says Johnson.
ASSERT is an acronym for "Alcohol and Substance abuse Services and Educating providers to Refer patients to Treatment." The program is only the second of its kind in the nation. D'Onofrio founded the program in fall 1999, modeling it on a similar one at Boston Medical Center, where she did her residency. She served on the faculty at Boston University School of Medicine before coming to Yale in 1996.
The Yale program works out of the Emergency Department because of the large number of patients who go there for treatment of trauma and illness that later prove to be the result of alcohol or substance abuse. An estimated 10% to 40% of patients in urban emergency departments around the nation are believed to have alcohol and drug problems. "It's a huge population," says D'Onofrio. The toll on society is equally great, she notes. Studies show that half of all major trauma cases are alcohol-related, costing the medical system and wider society billions of dollars and causing enormous harm to individuals and their families.
Other studies have shown that intervening with at-risk individuals to educate or facilitate their treatment can have an enormous impact. One controlled study found that an inpatient program like Project ASSERT led to a more than 47% reduction in injuries and rehospitalizations over a three-year period. Early intervention can also benefit adolescents who are engaged in high risk behaviors to reduce the potential for such harmful events as motor vehicle crashes or unsafe sexual encounters, says D'Onofrio. "We know it works."
When people seek emergency medical treatment, health care providers have a chance to identify at-risk individuals to guide them into treatment. "It's a perfect opportunity," she says. "We have a captive audience."
In its first year the Project ASSERT team evaluated some 5,800 patients and referred more than 700 patients to treatment centers. Nearly 2,500 other patients were given educational materials and other information about dangerous behaviors and health problems, ranging from smoking and sexually transmitted diseases to depression and domestic violence. To date, the team has screened over 12,000 patients.
Team members are on hand in the Emergency Department 8 a.m.-11 p.m. on weekdays, 8 a.m.-8 p.m. on Saturday and 8 a.m.- 4:30 p.m. on Sundays. When a patient clearly in need of help arrives during off hours, the emergency medical staff will hold them until a Project ASSERT team member arrives. "We're very integrated into the emergency room," says Johnson.
The program is currently funded by the Office of New Haven Fighting Back, a partnership between the Robert Wood Johnson Foundation and the City of New Haven to reduce substance abuse. The program also receives support from the University and Yale-New Haven Hospital. In its first year, Project ASSERT received funding from the State Department of Mental Health and Addiction Services as well. "Ideally," says D'Onofrio, "we'd have people on staff
24 hours a day. It's a relatively inexpensive program."
The Yale program has drawn national interest from many other medical centers looking to it as a model to create their own outreach services. In a related effort, D'Onofrio received a substantial National Institutes of Health grant for a clinical study using regular medical staff in the Emergency Department to intervene with problem drinkers.
Area programs that treat drug and alcohol abusers have come to rely on Project ASSERT. "They're right there at the heart of all the problems," says Josefina Feliciano, a caseworker at the Multicultural Ambulatory Addiction Services (MAAS), a New Haven outpatient substance abuse treatment center focused on Latinos and African Americans. "They're like an outreach arm for us. They make our services more powerful and they smooth out the process by clearing medical issues at the hospital first."
Project ASSERT health promotion advocate Blanca Torres recalls a pregnant, 26-year-old woman who was a heroin abuser and came to the emergency room because of pain initially believed to be related to her pregnancy. In fact, it was caused by withdrawal from the drug. According to Torres, the woman was "stuck with nowhere to go" because no facility was equipped to handle her dual condition of advanced pregnancy and withdrawal symptoms. Torres worked with the hospital and a detoxification center to initiate a coordinated treatment plan. Once her symptoms were stabilized, she was able to begin therapy for her addiction. "If we hadn't intervened," says Torres, "she would have been out on the streets."
According to D'Onofrio, the close ties between Project ASSERT and community treatment centers and other health and social service resources are crucial to the program's success. "The more we are involved with the community," she says, "the more it works."
-- By Marc Wortman
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