From interesting idea to demonstration to institutional program: Project ASSERT was established in 1994 in response to the need to improve the quality of care to patients with high risk and dependent unhealthy alcohol and other drug use. Since then it has served more than 50,000 patients at the Boston Medical Center ED, where Health Promotion Advocates (HPAs) screen for substance abuse and offer brief intervention and access to primary care, preventive services and substance abuse treatment.

The rationale for action: Project ASSERT was derived from evidence supporting the role of community health workers as casefinders, culture-brokers, educators and access facilitators in underserved areas (Swider 2002, Brownstein et al., 2006), and motivational interviewing as a strategy for behavior change (Miller & Rollnick, 1991). A landmark study at Massachusetts General Hospital 50 years ago provided inspiration for change. In a randomized, controlled trial, Dr. Chafetz enrolled 200 middle-aged, homeless, dependent drinkers to test a non-confrontational brief intervention delivered by trained residents and social workers. As a result, 40% of the intervention group but none of the controls kept five alcohol treatment appointments (Chafetz, 1962). If the intervention worked so well with alcoholics from Boston’s notorious Scollay Square, why not give it a try in a comparable ED? Project ASSERT was established in 1994 at Boston City Hospital with a demonstration grant from the national Center for Substance Abuse Treatment (CSAT)

Phase One, The CSAT Grant Years, 1994-1997-- 25,541 ED patients served: Dr. Chafetz improved the care of patients presenting with alcohol and drug-related illnesses and injuries, working with residents and social workers. Why, then, did Project ASSERT employ HPAs--community outreach workers hired to do “in- reach” in the ED under the direction of clinical staff? The HPA role was established in recognition of time constraints, overcrowding and resource limitations in the modern ED, and the need for a stable core of dedicated, experienced personnel with substance abuse treatment and community resource contacts, and protected time to educate and motivate patients to make healthier choices.

Case finding strategy: The Health Promotion Advocates (HPAs) performed universal screening, brief intervention and referral to treatment (SBIRT) at the patient bedside 16 hours daily, utilizing a health and safety needs history survey patients about access to primary care, preventive clinical screening, seat belt use, smoking, substance abuse, and experience of violence and depression. Alcohol and drug screening questions embedded in the oral survey included: 1) illicit drug use last year, 2) consumption of alcohol last 24 hours, along with admission of a drinking problem, 3) episodes of binge drinking, and 4) report of alcohol or drug-associated injury within the year. A health promotion approach--education and referral to medical services-- is readily accepted by patients who otherwise might feel stigmatized by an obvious emphasis on substance abuse. ED Brief Intervention Strategy: When patients screened positive for high risk/dependent drinking or illicit drugs, the HPAs utilized a motivational interviewing strategy known as the ED Brief Negotiation Interview or BNI, developed with Dr. Stephen Rollnick. The BNI, a behavior change strategy to establish trust, reduce resistance, and promote choice, contains the following elements: 1) asking patient permission to discuss alcohol/drug use, 2) exploring pros and cons of substance use, 3) promoting reflection about discrepancies between current life circumstances and future goals, 4) assessing readiness to change, 5) identifying patient strengths and prior successes, 6) providing a menu of resources, 7) negotiating a specific action plan. The quiding principles are providing nonjudgmental feedback, listening, affirmation and time for the patient to talk about change and articlulate in their own words the problem and possible solutions.

Boston City Hospital and Boston University Medical Center Hospital merged in 1996, and the future of ASSERT was uncertain. With supporting data, petitions and testimony from ED nurses, physicians, and patients, Project ASSERT won the Mayor of Boston’s Customer Service Award. The Boston City Council passed a resolution recommending funding. Shortly after, Project ASSERT became a line item in the ED budget and has continued as an integral part of the Emergency Department staff and budget under nursing management

Phase II: The evolution of the Project ASSERT model (1997 to the present) The change from City Hospital to private status and from grant to institutional funding created new challenges. Central Intake, which provided addiction services, was relocated away from the ED to a hard-to-find spot several blocks away, with reduced staff, hours, and accessibility. These changes forced Project ASSERT to implement an aggressive, time-consuming referral process requiring hourly calls to a long list of facilities to locate beds and negotiate on behalf of patients with private or managed care insurance for prior approval. They utilize the marginal capacity of the treatment system to facilitate access. In addition, HPAs track down medical staff to complete medical and psychiatric clearance examinations when required. ED physicians document Project ASSERT consultations in the electronic medical record, and the HPAs complete a template in the elctronic record. When beds are unavailable, HPAs provide low impact case management and referrals to nearby shelters forthe homeless until placement is found. Project ASSERT in the last few years has faced a serious access problem. Depite all efforts 1/3 of ED patients requesting detox can not be placed in a detox because no beds are available or they lack insurance coverage.

In Phase II, more referrals were made directly to detox and primary care and fewer to central intake and outpatient addiction programs. Overall, Project ASSERT allocated greater resources for crisis care for dependent drinkers than for high risk drinkers. The majority of Phase II patients were referred to Project ASSERT directly by ED staff. They are paged over head and are able to take discharged patients to their office to conduct the intervention and complete placement. There was simply no time for HPAs to perform universal screening room-to-room for the high risk drinker and drug users as they done in the earlier years.

HPAs are necessary but not sufficient: The Project ASSERT model requires active participation of clinical staff on a number of levels. ED providers have gotten better at detecting and referring patients to Project ASSERT when the visit is obviously alcohol-related. However, unless providers utilize validated screening questions instead of relying on ‘smell of alcohol on breath’ or profiling obvious alcohol-related visits, they will continue to miss hidden dependent drinkers, and they will only rarely detect high risk drinkers.

Recognizing that our original intent to broaden the base and provide real-time universal screening and intervention across the spectrum of high risk to dependent drinking has not yet been realized, we have increased efforts to enlist ED provider in alcohol screening and motivational intervention. The success of our efforts was demonstrated in a national NIAAA/SAMHSA funded Alcohol SBIRT study at 14 emergency departments during 2004, utilizing lessons learned from Project ASSERT at Boston University and Yale University, involving 400 physician. nurse practitioners, nurses, physician assistants and social workers. Of the 7,751 patients screened, 2,051 (26%) exceeded the low-risk limits set by National Institute of Alcohol Abuse and Alcoholism and 1,132 (55%) of eligible patients consented and were enrolled (581 control, 551 intervention). Six hundred ninety-nine (62%) completed a 3-month follow-up survey, using the interactive voice response system. At follow-up, patients receiving a Brief Negotiated Interview reported consuming 3.25 fewer drinks per week than controls, and the maximum number of drinks per occasion among those receiving Brief Negotiated Interview was almost three quarters of a drink less than controls. At 3-month follow-up, 37.2% of patients with CAGE less than 2 in the intervention group no longer exceeded National Institute of Alcohol Abuse and Alcoholism low-risk limits compared with 18.6% in the control group. (The Academic ED SBIRT Collaborative. An evidence based alcohol SBIRT curriculum for ED providers improves skills and utilization. Subst Abuse 2007;28:79-92; The Academic ED SBIRT Collaborative. The Impact of Screening, brief intervention and referral for treatment (SBIRT) on Emergency Department patients’ alcohol use. Ann Emerg Med 2007; 5:699-710).

The greatest challenge in an ED with 100,000 visits yearly is to provide universal screening and brief intervention for those non-dependent, high risk alcohol and other drug users. The prospect of physician CPT codes and CMS reimbursement codes may provide incentive for greater utilization of SBI by our housestaff and faculty who receive yearly training in SBIRT. We hope this will lead to more widespread and consistent screening and brief intervention services. (Bernstein E, Bernstein J. Commentary-- SBIRT: Qualified trained assistants are necessary but not sufficient. Acad Emerg Med 2005; 12: 786-787).

Recent peer reviewed published study: To test the Project ASSERT peer model a randomized, controlled trial was conducted with 3 and 6 month follow-up by blinded observers. Drug abstinence was documented by RIA hair testing. Analysis was limited to enrollees with drug-positive hair at baseline. Results. Among 23,669 patients screened 5/98-11/00, 1,232 (5%) were eligible, and 1175 enrolled. Enrollees (mean age 38 years) were 29% female, 62% non-Hispanic Black, 23% Hispanic, 46% homeless. Among those with positive hair at entry, the follow-up rate was 82%. The intervention group was more likely to be abstinent than the control group for cocaine alone (22.3% vs 16.9%), heroin alone (40.2% vs 30.6%), and both drugs (17.4% v s 12.8%), with adjusted OR of 1.51-1.57. Cocaine levels in hair were reduced by 29% for the intervention group and only 4% for the control group. Reductions in opiate levels were similar (29% vs 25%). (Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alc Depend 2005; 77:49-59).

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Published data from Project ASSERT: Among 7,118 patients screened by Project ASSERT during 12 months of 1995-6, found 41% positive for high risk/dependent drinking or drug use: 31% female, 61% Black, 11% Hispanic, 61% without a regular doctor, 80% smokers, 8% reporting alcohol/drug-related injury, and 24% mildly/moderately depressed. Among enrollees, 10% accepted referral to detox, 41% to outpatient, acupuncture or central intake for placement, 34% to AA/NA, and 47% to primary care. At 3-month follow-up, half had kept referral appointments, and more than half reported reduced drinking, drug use and related consequences (Bernstein E, Bernstein J, Levenson S. Project ASSERT: An ED based intervention to increase access to primary care, preventive services and the substance abuse treatment system Annals of Emergency Medicine 1997; 30:181 189).

Unpublished data: From 1999-2005, Project ASSERT provided services to 27,101 patients: 32% female; 46% Black, 16% Hispanic; 27% without primary care, 28% unable to afford medications, 61% smoked, only 24% always used a seat belt, 31% with an alcohol or drug-related injury, and 20% mildly/moderately depressed. Among the 15,786 who drank in excess of NIAAA guidelines or used drugs within 30 days, 44% were placed in detox, 9% in outpatient programs, and 42% referred to NA/AA. Moreover, 11, 315 patients who screened negative for substance abuse were referred for primary care, and 42% received an array of other mental health and preventive referrals. (Abstract and poster Presented at APHA Annual meeting Boston 2006).

unpublished results for costs $6.50 per client screening $32.78 per client intervention,

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