National Center for Physician Training in Addiction Medicine SBIRT Milestone

Webinar Series 

SBIRT Curricular Resources: Level 2Webinar #3

October 16, 2015

Richard D. Blondell, MDShannon Carlin-Menter, PhD

Urmo Jaanimägi

(Supported by a grant from the Conrad N. Hilton Foundation to the American Board of Addiction Medicine Foundation)

2015 -2016 SBIRT Milestone Webinar Series

• July 17: Baseline

• August 21: 1st Quarter

• October 16: 2nd Quarter

• February 19: 3rd Quarter

• May 20: Final Evaluation

2

Last Webinar

• Review and know some basics of SBIRT and Core Competencies

• How to start developing more advanced SBIRT skills among the fellows

• Sharing experiences – what has been done, what works, what does not work in other ADM Fellowships

• How to complete the new SBIRT Baseline AND Core Competency Milestones

3

Things That Should/Could Be Done by Now

• Complete Baseline SBIRT Milestone

• Arrange to get the fellow to next level (from Baseline toward Quarter 1/Next level)

• From level 1 to 2

4

Today’s Webinar

• Today’s Objectives:

• Progress on SBIRT Milestone

• Next level resources

• Sharing experiences – what has been done, what works, what does not work in other ADM Fellowships

5

SBIRT Milestone ONGOING Evaluation Process, Data Collection

6

Program DirectorFaculty/Staff

Fellow

Database/System

Observes

Informs

Obser

ve

s

Enters

SBIRT Milestone PROGRESS Report, Data Synthesis (Once a Quarter)

7

Program DirectorFaculty/Staff

Fellow

Database/System

Observes

Feedback/data from other faculty, staff, patients

Obser

ve

s

EntersQuarterly Meeting

Data Synthesis:Checks boxes on Milestone Report

GME Office Summary Reports; Other Data: paper evaluation, video, chart review

ABAMF(Buffalo)

SBIRT Milestone Evaluations

The Milestone data is being used by the Evaluation Team at UB to measure the progress that Fellows

make from Baseline to the end of their Fellowship in Addiction Medicine.

This data allows us to track and monitor:• The progression of the Fellows competency

levels from baseline to completion;• Track the total number of physicians & other

health professional that the Fellows trained during their Fellowship;

• What types of Curriculum Activities each Program developed and utilized with the Fellows; and

• The efforts and accomplishments of the Fellowship Programs and their Fellows.

SBIRT Milestones Results 2014-15 Fellows

Start of FellowshipBaseline

Quarter 1

Quarter 2

Quarter 3

Graduation Quarter 4

0.89

2.07

3.05

0

5

3.60 4.25

Average SBIRT Milestone Scores by Quarter

Curriculum Development 2014-15 FellowsCollected from open-ended Questions

Start of FellowshipBaseline

Quarter 1

Quarter 2

Quarter 3

Graduation Quarter 4

Reading prior to fellowship

Self-study guides/web resourcesWeekly Didactic Series

ReadingsRoleplays

MI Training/WorkshopsObservations/ Modeling

Standardized Patient scenariosMentoring & Direct Supervision

Role Plays & RemodelingDidactics

Journal Club on SBIRTSelf-guided study

Conferences & online training

Providing SBIRT in a clinical settingSBIRT Presentations

Developing relationshipsAttending Workshops

RoleplaysMentoring

Self-Guided studyDidactic Sessions

ABAM examResearch

Article Collaborations

Feedback & Assessment 2014-15 FellowsWord Cloud

Fellow Self-Reflections 2014-15Open-Ended Examples Collected

• “A key lesson that I've learned is to be self-aware. One trainer cautioned that the clinician should never be the most motivated person in the room - driving the idea that the motivation and change needs to come from within the patient. “

• “In this past quarter I feel that I have learned quite a bit about SBIRT through my detailed literature review to prepare for my SBIRT journal club presentation.”

• “The most rewarding part remains being the 'change agent' within the system by helping to decrease patients ’ resistance to change', and help patients to find their own reasons and motivations for making changes regarding substances in their lives.”

• “Using the SBIRT model has been helpful and has given me skills as a health care providers to discuss substance use behavior changes with my patients.”

• “I have a desire to change systems in low resource areas regarding access to appropriate addictions resources. Going beyond screening we must look at how to best engage those we screen and work to develop good follow-up and actual change.”

SBIRT Milestones Results 2015-16 Fellows

Start of FellowshipBaseline

Quarter 1

Quarter 2

Quarter 3

Graduation Quarter 4

1.27 *

? No data (only two programs)

?

0

5

? ?

Average SBIRT Milestone Scores by Quarter

* N = 22 Fellows

Baseline Response Rates: 22/45 fellows= 49% 12/27 programs= 44%

Curriculum Development 2015-16 FellowsCollected from open-ended Questions

Start of FellowshipBaseline

Quarter 1

Quarter 2

Quarter 3

Graduation Quarter 4Attended Training Course (SBIRT)

Skills Development Session in MI

Inpatient Consult Service experienceSBIRT Web Resources

ReadingsDirect observation in clinics

Teaching session with Residents in Clinic

SBIRT Milestone Data – Next Steps

Using the Data we have gathered from the Milestone Evaluation we hope to:

• Track the progress of all fellows from Baseline to Graduation and Quantify the effectiveness of the Fellowships programs (in terms of SBIRT – the Hilton Grant focus)

• Utilize the Qualitative information gathered from the open-ended questions to understand HOW the Fellows learn and HOW they participated in the Fellowships.

• Map the progress to the Milestone level achieved per quarter and understand what Curriculum “tools” each fellowship utilized.

• Understand what works and what doesn’t work.

SBIRT Milestone Data – Next Steps

We want to tell the story of YOUR efforts to train physicians in Addiction Medicine with SBIRT as the focus, but

to do so, we need milestone data!

If you haven’t done so already, please submit your Baseline & Quarter 1 Milestones to Urmo Jaanimägi.

Thank you!

6 ACGME and ABMS Core Competencies

• Patient Care and Procedural Skills (PC)

• Medical Knowledge (MK)

• Practice-Based Learning and Improvement (PBLI)

• Interpersonal and Communication Skills (ICS)

• Professionalism (PRO)

• Systems-Based Practice (SBP)

17 M

GOAL Achieve Milestone Level 3

Level 2 Level 3

• This fellow performs basic SBIRT activities and creates a non-judgmental safe environment to actively engage patients in SBIRT.

• This fellow maintains the appropriate documentation of SBIRT activities in the medical record.

• This fellow is highly skilled with SBIRT and Motivational Interviewing techniques.

• This fellow continuously connects and communicates with community addiction treatment resources that are able to accept patient treatment referrals.

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An SBIRT Implementation and Process Change Manual for Practitioners (CASAColumbia)

• This manual covers four main areas:

• The components of SBIRT

• Process improvement strategies (implement and sustain)

• Planning your SBIRT program to fit your agency using tailored implementation strategies

• Toolkit and worksheets to guide implementation of SBIRT

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Motivational Interviewing

• Chapter 1: Why include motivational interviewing in medical training?

• Fostering constructive patient-doctor relationships

• Motivational interviewing works

• Applicable in managing medical conditions with behavioral component

• Making effective use of limited time, energy, and resources

• Guarding against burnout (spirit of MI)

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Referral to Treatment in Pediatrics(University of Maryland)

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Types of Treatment

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• Outpatient (Return to see PCP)

• Outpatient (Referral to specialty TX)

• Inpatient (residential, rehab, detox)

• Medication Assisted (e.g., buprenorphine)

• 12-Step Groups (AA, NA, AlAnon)

• Non-12-Step Support Groups (Smart Recovery)

Referral

24

Referral

25

Referral

26

Referral

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Self-Help-, 12-Step Programs

• The evidence for AA effectiveness is quite strong:

• Rates of abstinence are about twice as high among those who attend AA

• Higher levels of attendance are related to higher rates of abstinence

• These relationships are found for different samples and follow-up periods

• Prior AA attendance is predictive of subsequent abstinence

• Mechanisms of action predicted by theories of behavior change are evident at AA meetings and through the AA steps and fellowship

28(Kaskutas 2009)

Self-Help-, 12-Step Programs

• Why are 12-Step Programs Effective?•Group dynamics clearly are in effect in 12-step meetings

•Growth of the self:• Improved self-governance• Self-Awareness• Self-Deflation

•Experiencing Empathy

•Spirituality

(Ries, Fiellin et al. 2014) 29

Self-Help-, 12-Step Programs

• Referral to AA

• Successful referral to a 12-Step program requires support and contact.

• Systematic encouragement

• Clinician called AA member

• Patient/client talked briefly with member

• Arranged meeting and ride

• AA member called before meeting to remind

• Result: 100% attendance ( N = 10)

• Standard referral: 0% attendance (N = 10)

(Sisson and Mallams 1981) 30

UB ADM Fellow• Curriculum Guide Resources

• Help start seeing the practical and logistical side of implementing SBIRT in a new setting after fellowship

• The change manual from CASAColumbia and the paper by Bray comparing costs of different programs are helpful for this

• The Maryland module on Pediatrics is full of good information which is helpful before starting the Renaissance rotation in a few months. It explains how to choose level of care and where to refer teens as well as legal info I should know.

• The SAMHSA link is helpful. I can use it to find counselors and treatment clinics anywhere. It would also be a helpful resource to share with community members. I think back to my conversation with a pharmacist at church who wanted to know more about referral to treatment centers. This is an easy resource to share with others.

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Programs Share

• Previously, Dr. Anna Lembke has agreed to share (program director’s perspective)

• Others willing to share today?

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Open Discussion

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Summary

• Training fellows is a stepwise process• From screening to BI and RT

• Fellows training others

• Can use existing materials for:• Training in BI (e.g., Miller & Rollnick)

• Formulating RT process (e.g., SAMHSA locator)

• Questions, comments, discussion

• What’s next

34

References

• CASAColumbia, "An Sbirt Implementation and Process Change Manual for Practitioners", CASAColumbia http://www.casacolumbia.org/sites/default/files/files/An-SBIRT-implementation-and-process-change-manual-for-practitioners.pdf.

• Douaihy, Antoine, Thomas M Kelly and Melanie A Gold. Motivational Interviewing: A Guide for Medical Trainees: Oxford University Press, 2015.

• Kaskutas, Lee Ann. "Alcoholics Anonymous Effectiveness: Faith Meets Science." Journal of addictive diseases 28, no. 2 (2009): 145-157.

• Miller, William R and Stephen Rollnick. Motivational Interviewing: Helping People Change: Guilford press, 2012.

• Ries, Richard K, David A Fiellin, Shannon C Miller and Richard Saitz. The Asam Principles of Addiction Medicine: Lippincott Williams & Wilkins, 2014.

• Sisson, R. W. and J. H. Mallams. "The Use of Systematic Encouragement and Community Access Procedures to Increase Attendance at Alcoholic Anonymous and Al-Anon Meetings." Am J Drug Alcohol Abuse 8, no. 3 (1981): 371-6. 35