Terry Horton, M.D., saw an opportunity for early intervention. 

Patients showed up in Christiana Care Health System’s emergency department (ED) with illnesses caused by substance use disorders. The ED team knew they needed help for more than the strokes, broken limbs, high blood pressure and seizures. But it didn’t know how to get them to take the steps that could change their lives.

The ED visit was a “reachable moment,” says Horton, chief of the Wilmington, Del.-based health system’s division of addiction medicine. A former medical director of Phoenix Health, the nation’s largest nonprofit addiction treatment organization, Horton was keen on finding someone who could engage with patients at the hospital bedside.

“I learned an important thing at Phoenix Health,” Horton says. “When someone raises their hand for help it is a fleeting moment and you have to be there to grab that hand. Because if you’re not, it’s gone.”

He believed strongly that peer counsellors – “people who have recovered from addition to help those suffering from addiction” – could build rapport with patients and motivate them to seek treatment and rehabilitative care once they left the hospital.

His support for the idea led to “Project Engage,” first piloted in 2008 as a partnership between Christiana Care and the behavioral health agency Counseling and Community Services, and a full-fledged hospital program since 2011.

With the nation gripped in a drug crisis, Project Engage has gained attention as an early-intervention program for substance use disorders that is improving patients’ outcomes and reducing costs.

Drug deaths in the U.S. rose at the steepest rate ever to the highest level in recorded history in 2016, claiming more than 60,000 lives, and data suggest deaths from opioids and other drugs will continue to increase in 2017.

Project Engage screens patients who exhibit signs of a substance use disorder – people at clear risk of doing further harm to themselves and others, and becoming frequent visitors to the ED.

If the screening establishes a link between substance-using behavior and patients’ presenting illness, a nurse will ask if they would like to talk to a peer counsellor – called an “engagement specialist” – about the problem. If they say yes, the engagement specialist will visit them at the bedside. Unlike a clinician or social worker, they speak the same language as the patients who need treatment. Later, the counsellor will work with one a hospital social worker to connect patients to resources in the community that put them on the path to recovery.

 “There is almost an automatic level of trust because the peers have been there,” says Lynn Fahey, CEO of Brandywine, which provides the counsellors. “They can relate to what the patient is going through. They have credibility.”

Of the approximately 1,500 patients with substance use disorder offered help through Project Engage, about 30% accept treatment, Horton says. Virtually no patients opted for treatment before the program began.

An analysis of hospital data shows an average annual savings of about $6,000 per patient when engagement specialist have intervened, Horton says. “We’ve made significant strides towards achieving our basic goals: break down the stigma, identify and manage rapid withdrawal and move patients on to care in the community so we can address root cause issues,” he says.

To succeed, “you need to have someone in the hospital or health system on the medical side who believes 100% in the program and the process – a champion like Dr. Horton,” says Brandywine’s Fahey. “And obviously you need to hire the right [counselors] who understand that their job is about doing a little bit of everything, and you have to believe there is a chance that these folks can get better if we provide them with the right services at the right time.”   

Horton sees growing public support for addressing substance use disorder as a chronic health problem that requires treatment, “because the epidemic is affecting everyone in all walks of life.”

He testified in May before a Senate committee about the scourge of the opioid epidemic, warning Congress that it is “critical, urgent and getting worse.”

He says Project Engagement reflects a “new way of thinking about substance use disorders” in a health care world that is increasingly focused on population health management.

“One of the great promises of the Affordable Care Act,” says Horton, “is that health systems, if they invest in this type of care, can start to leverage the savings they have accrued by preventing that second or third or fourth endocarditis, and use those savings to improve the continuum of care and address a brain disorder that has been neglected for decades.”  




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