With all they have on their plates, emergency personnel generally are not enthusiastic about taking on new preventive health initiatives, but a unique program that aims to identify and respond to risky and unsafe behaviors in adolescents and young adults who present to the ED has won over both providers and staff at Boston Medical Center (BMC).
At the heart of the approach is the creation of a new health promotion advocate (HPA) role, a position designed to encompass both clinical medicine and public health in the emergency setting. Individuals serving as HPAs are trained to connect with young patients, identify risks as well as needs, and to use motivational interviewing techniques to nudge patients away from risky or unsafe behaviors. Also important, HPAs are armed with an impressive array of resources they can provide to young patients, ranging from substance abuse treatment and mental healthcare to housing, food assistance, or even help in obtaining a general education diploma.
While it is difficult to document preventive outcomes, one new study shows that the approach is effective at identifying and connecting young patients with needed care, much of it focused on substance abuse. Between 2009 and 2013, investigators reported that HPAs screened 2,149 pediatric patients 14-21 years of age, and referred 834 of these individuals for services to address identified health risks. Of 785 patients in this group who screened positive for at-risk substance abuse, 636 received a brief intervention, and 546 were connected to specialized substance abuse treatment.1
The conclusion of the study was that HPAs who work as part of the pediatric emergency medicine team can extend the benefits offered in the ED beyond treatment of the presenting complaint.
Earlier studies have shown that the HPA model can be leveraged with other interventions to positively affect drug and alcohol use behaviors and increase access to primary care.2-4 Although the results are modest, emergency providers at BMC approve of the HPA role, noting that it gives them a shot at connecting high-risk patients with the kind of interventions that can positively affect their overall healthcare trajectories. Further, they believe it’s an approach that may make sense for other EDs, especially those that serve high-risk populations.
Focus on Health, Safety Needs
The HPA role grew out of similar work that was happening with adult populations at BMC through a Substance Abuse and Mental Health Services Administration-funded program called Project ASSERT (Alcohol & Substance Abuse Services, Education, and Referral to Treatment), explains David Dorfman, MD, chief of the division of pediatric emergency medicine at BMC.
“We started to then apply some of these approaches to patients in the pediatric ED, realizing that we were seeing adolescents and young adults with drug-related issues,” he says. “Then, once we had the resource [of an HPA] through our research efforts, we then decided it was working well, and people appreciated it.”
Another motivating factor for adoption of the HPA role in the pediatric ED was the fact that social workers there already had their hands full.
“Most of their issues were about neglect and abuse, and [these matters] were taking up most of their time,” Dorfman says. “We felt that we were missing a large group in our population that we could help with other kinds of social and lifestyle issues, and that we could be doing more for these patients.”
The model used in Project ASSERT was adapted and refined to fit the needs of adolescents and young adults by Edward Bernstein, MD, an emergency medicine physician and the director of Project ASSERT at BMC.
“It’s not just about alcohol and drugs. These patients have an array of issues ... and that came through in our research,” he says. “We had high rates of PTSD, depression, anxiety, and [there were] children with special needs.”
Bernstein developed a health and safety survey for the HPAs to use that encompasses everything from safe sex and drug and alcohol use to smoking, behavioral health, and access to primary care.
“Basically, [the HPAs] go room to room without any profiling and they just introduce themselves as health promotion advocates,” he explains. “They ask if the patient has a few minutes to chat and find out how things are going for [the patient] ... and what sort of needs they have.”
HPAs may be able to provide resources to patients, and they may work with patients to develop a plan. “It is like a friendly conversation, and nobody has really turned them down,” Bernstein offers. “If parents are in the room, [the HPA] might ask them to step out after informing them what is in the survey.”
The overarching goal of the program is to interrupt the problematic health trajectory that lies ahead for many of the young patients who present to the pediatric ED — problems that clinicians already can see in the adult population, Bernstein says.
“We definitely wanted something that was trauma-informed, respectful, and that young people could relate to ... so we [integrated into the role] the peer model of community in-reach, motivational interviewing, and screening and intervention,” he says.
New data on the approach collected between January 2015 and November 2016 found that more than one-third of patients approached by HPAs lacked access to primary care, and so these patients were referred to an adolescent clinic, Bernstein explains.
“The big issue was safe sex practices if the patients were sexually active; 65% of those surveyed were sexually active, and 43% didn’t use any birth control or contraception,” he says. These patients received safe sex education and were offered condoms.
Bernstein adds that 65% of patients surveyed used drugs or alcohol in an unsafe way, with more than half using marijuana and alcohol. Many of these patients received alcohol and drug education along with a brief motivational interview. Patients identified with severe problems in this area were linked with either an inpatient or outpatient program.
“We have a lot of internal resources at BMC. It is sort of a hub for addiction and at-risk alcohol and drug use,” he says. “We provide these services, and we also have community linkages to a lot of other resources.”
Initially, the pediatric ED-based HPAs tended to work with the social worker, identifying patients potentially in need of screening through electronic flags, but the approach has evolved to where HPAs round on all patients. “You can walk around and very easily pop your head in each room and round with the nurses as well as always be an active presence on the unit,” explains Karin Rallo, RN, the nurse manager in the ED at BMC. “It is much less restrictive to be on the unit rounding than it is to be in the office going through medical histories.”
Further, Rallo stresses that active rounding is imperative given that many patient needs are not captured on medical charts. For example, patients often need food or housing, or there may be problems at home that interfere with their ability to access care or to get to school. It may take only five minutes to effectively intervene, she observes. “In some cases, people have complex needs that take longer, but other people have needs that are very simple,” she says, noting that HPAs can direct patients to nearby food banks when basic necessities are an issue.
Rallo stresses that the patient population at BMC is very challenging demographically. “One of the primary complaints in the pediatric ED here is homelessness, so there is a lot of room to help,” she says. Further, she notes that the HPA program has grown to where the nurses, physicians, and HPAs collaborate well together.
“We have huddles in the pediatric ED three times a day, and the health promotion advocates are at those huddles,” she says. “Not only are they roaming around the unit and surveying who we have here for patients, but they are also at the huddles to hear pressing issues that we may be having as far as flow issues, bed capacity, and things like that. And their ears are already turning from that perspective to assess what they can do to help patients.”
For example, Rallo notes that when the ED is backed up with patients, it may mean that the HPAs have more time to spend with patients, and they may be interacting with people in the waiting room. When a medical or social work-related need is identified through the health and safety conversation, the HPAs are trained to work with the nurse and the primary emergency physician to arrange for appropriate referrals.
Dorfman notes that there has been no problem fitting the HPA role into the workflow of the ED. “Even if the place is busy, most ED visits are long, with a lot of downtime between tests,” he explains. “When there is a break between nursing or physician interventions and the patient is in the room alone, [the HPAs] will go in and introduce themselves, explain what they are there for, and start a conversation with the patient.”
If the nurse comes back with an IV, the HPA will step outside until the procedure is completed, says Dorfman, noting that there is never any disruption to the care process. “The people who [serve as HPAs] have been well-integrated into the role, and the nurses and the physicians really appreciate having them there,” he says. “The advantage is that this is an extra person, and the physicians and nurses understand that [the HPA role] is important.”
In cases in which a patient is in a lot of pain or distress, the HPA will defer interacting with this person until later in the visit when he or she is more comfortable, Dorfman explains. “Obviously, there are some patients who are in and out and never get approached by the HPA,” he says. “It is really about approaching as many patients as we can and coaching the HPAs to be as proactive as possible.”
Bernstein stresses that there is no required trigger to prompt an HPA to interact with a patient. “We are not profiling. We are not waiting until someone has a serious problem to talk to them,” he says. “This is primary prevention.”
However, any social or other issues that are uncovered by the HPA are documented in the medical record. “There is a page that addresses all these needs, whether it is food security, housing security, or whatever the need may be,” Bernstein explains. “All these needs are identified and that record goes with the patients to primary care.”
Nurture HPA Candidates
By training, the HPAs come from myriad health backgrounds, Bernstein explains. “The last several [HPAs] had public health backgrounds because this is really trying to integrate public health into clinical practice, so those folks did very well in the role because they were health educators,” he explains. “We educated them at our institute for motivational interviewing and screening.”
Alternatively, one HPA had a license in drug and alcohol counseling as well as a mental health background in a community-based program. “The HPAs need to have some background in adolescents, good communications skills, and they need to be able to be flexible to fit in with the busy ED and not be intimidated,” Bernstein offers. “They can’t be sitting in a corner waiting to be called. They have to be really good at mixing [with different types of people], respecting diversity, and communicating well with people of all backgrounds.”
The HPA program is fortunate to have a ready supply of interns available through the Boston University School of Public Health. The interns work under a supervising HPA, learn about the role, and help the HPA round on patients and provide services. They also can help bridge gaps when the HPA position is open.
While the HPAs have diverse educational backgrounds, they must be able to approach patients in a friendly, supportive, nonjudgmental manner, Bernstein observes. “That is what our training is about, along with how to use the health and safety survey, how to get the most out of it, how to build resources, and then make the referrals,” he says.
With any prevention effort, it is difficult to document benefits or to show a direct link to a particular intervention. Further, it would take years of very expensive research to determine whether an HPA-driven intervention produced the intended effect of curbing unsafe or unhealthy behaviors. However, Bernstein observes that BMC has developed a mission geared toward addressing the social determinants of health, and the HPA approach fits this mission well.
“The reality is we have our fingers on the pulse of a person when we check him or her out in the ED, but we also have our fingers on the pulse of the community, and we get to see patterns,” Bernstein says. “That is how we developed some of our programs. We get to identify things that pass the threshold of a normal visit.”
Program administrators emphasize that a lot of the difficulties young people face do not arise from medical problems, but rather inadequate housing or education, food insecurity, or other social issues. Many young people cope with their problems through drinking or drug use.
Bernstein recalls the case of one young woman who was in the ED because of her marijuana use. “In questioning her and trying to find out what was going on, she said her mother had been overdosing on heroin, and so we were able to provide her with a naloxone rescue kit,” he says. “We actually found out through follow-up that she had actually used it and saved her mother’s life.”
Bernstein stresses that the idea behind the HPA program is not to wait for that moment when a person has a sexually transmitted disease or another bad outcome.
“We want to avoid that, but it is a teachable moment when people are a little bit more open to hearing what you have to say,” he explains. “For those people who are seriously impaired by risky behaviors, we definitely want to connect them with things that are much more permanent, so the treatment system is there for them.”
One outcome that should not be overlooked is the effect the HPA program has had on practitioners, Dorfman says.
“It has had a very positive effect on nursing and the physicians,” he says. “It lessens your sense of hopelessness sometimes about your patients.”
However, integral to this provider satisfaction is the array of resources that the emergency staff have at their disposal.
“When we identify someone [with a drug or alcohol use problem], we can at least offer them the chance of a real referral to outpatient management, and that has been a great thing,” Dorfman says. “And that is mostly about opioids.”
Key to the success of the HPA program is collaboration and knowing who the patient population is, Rallo notes.
“There is really no substitution for hands-on rounding in the department. You have to have an active presence to know what is going on,” she says.
For instance, if there is a new drug in the community that is affecting kids, everyone in the ED must be up to speed on this development, Rallo notes.
“The dynamic changes from day to day, and it can change from season to season, so really making sure everyone is on the right page is important,” she says. “Nurses will often let the health promotion advocate know that there is a concern if the HPA hasn’t had a chance to round on a patient yet or if he or she has been tied up with somebody else,” Rallo says.
Conversely, HPAs will let nurses know about new resources they have identified and how they can be accessed during times when the HPAs are not on campus, Rallo advises.
“Collaboration is key ... and not being afraid to poke your head in [a room] and actually talk to a family,” she says.
Bernstein stresses that starting something like the HPA program begins with a culture in the ED that embraces patients with drug or alcohol use problems on an equal footing with patients who present with other medical problems.
“Our diabetics don’t always eat the right foods or exercise or show up at their appointments. They often come into the ED out of control, and we don’t beat up on them,” he says. “I think there needs to be more of a sense of responsibility that our mission is beyond treating and streeting.”
- Bernstein J, Dorfman D, Lunstead J, et al. Reaching adolescents for prevention: The role of pediatric emergency department health promotion advocates. Pediatr Emerg Care 2017;33:223-229.
- Bernstein J, Heeren T, Edward E, et al. A brief motivational interview in a pediatric emergency department, plus 10-day telephone follow-up, increases attempts to quit drinking among youth and young adults who screen positive for problematic drinking. Acad Emerg Med 2010;17:890-902.
- Bernstein E, Edwards E, Dorfman D, et al. Screening and brief intervention to reduce marijuana use among youth and young adults in a pediatric emergency department. Acad Emerg Med 2009;16:1174-1185.
- 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. Ann Emerg Med 1997;30:181-189.