Engaging patients at the hospital bed

From his days as medical director of what at the time was the nation's largest nonprofit addiction treatment organization, Terry Horton, MD, knew that hospital systems could reduce unnecessary costs and make a difference in patients' lives if they maximized the opportunity to address problematic substance use in their hospitalized patients. He also knew how he wanted to design that effort in terms of staffing.

“From my experience at Phoenix House I was very keen on using peer counselors rather than social workers,” says Horton, now chief of the Division of Addiction Medicine at Christiana Care Health System, Delaware's largest health system. That would be confirmed, Horton recalls, when a social worker in the hospital system earnestly asked him whether he was intending to attract active drug addicts to the hospital.

Peer workers, called “engagement specialists” in the Christiana Care program, have gained substantial credibility with hospital staff and are helping hospitalized patients find a path to recovery in the Project Engage initiative, for which Horton serves as medical director. A nonprofit behavioral health organization provides the peer workers for the project.

“When someone is in the hospital, there is a window of opportunity where the person might be saying, 'Now it's time for me to change my life,'” says Lynn M. Fahey, PhD, CEO of behavioral health agency Brandywine Counseling and Community Services. “The peer piece is critical—I can't overstate that. There is almost an automatic level of trust, because the peers can share that they too have been in a hospital bed.”

Integrating expertise

“We in the hospital here don't have expertise in peer counseling,” says Horton, who has worked at Christiana Care since 2007. “It is important for us to have a reputable service do the work.”

Nurses at the hospital serve as the liaison to peer services for hospitalized patients. A nurse will ask a patient for permission to talk about drinking. If a link is established between substance-using behavior and the person's presenting illnesses, the patient will be asked, “Would you like someone to speak with you about that?” If the patient is amenable, the engagement specialist then will arrange to speak with the patient at the bedside.

“At Christiana Care, we've had a sensitivity to the needs of all of our patients, but at times our caregivers can be a bit frustrated, particularly when over and over again they see certain patients and they feel they don't have a lot to offer them,” says Virginia U. Collier, MD, the Hugh R. Sharp, Jr. Chair of Medicine at Christiana Care. “This is giving them hope.”

Horton says the health system funded the initial year of Project Engage, then received an anonymous gift of around $1 million over three years to keep the initiative going after some promising data about its effects were released.

Fahey says the peers use Motivational Interviewing (MI) techniques as the foundation of their work with patients. Because the cultures of behavioral health and primary care organizations differ so greatly, she says that a priority in the hiring of engagement specialists has been “finding individuals who can navigate both systems successfully.”

She adds that it has become common for Brandywine to work with peers who have work experience in another field besides substance use treatment. Horton says the engagement specialists have had a variety of work backgrounds, from pipefitting to owning fast-food restaurants.

“Their desire to help people who are suffering is what motivates them,” Fahey says of the engagement specialists. As such, it has become common for program leaders to hear of peers taking patients to a food pantry after they have been discharged from the hospital, or raising money to help relocate a patient closer to family and friends.

“Nothing is 'not my job'; to them,” Fahey says of the engagement specialists.

Measures of success

Leaders involved with Project Engage say they look at several variables to evaluate the success of the initiative. Collier says one important measure involves the degree to which a conversation with an engagement specialist leads to a patient's follow-through with a recommended treatment program. She says this is now happening around one-third of the time, a rate far in excess of what is seen with usual care.

She adds that Christiana Care also looks for trends in future primary care visits for hospitalized patients, as well as potential decreases in hospital readmission and emergency room utilization. The signs here have been encouraging as well.

Another important component of Project Engage's success has been the effect that participation has on strengthening the recovery of the participating engagement specialists.

Leaders say that in perhaps the most important lasting effect from a service perspective, Project Engage is shifting the hospital system's mindset about patients with substance use problems. The peers offer living proof to hospital staff that patients with a substance use history can get better, Fahey says, and they also demonstrate that non-credentialed professionals can play a pivotal role in managing patients' health conditions.

“They are showing how important it is to make room for peers in healthcare reform and the payer mix,” Fahey says.

Horton adds that health reform has added to the urgency of integrated care efforts such as this. “The [Affordable Care Act] puts the onus on hospital systems to be accountable for the care of populations,” he says. “Drug treatment functions as a rope bridge, but there are missing slats. … If we can get patients out of the revolving door of hospital, ER and community, and we can leverage the savings from reduced admissions and use it to build back the rope bridge, we can rebuild our systems of care.”