1. National Center for Physician Training in Addiction Medicine SBIRT Milestone Webinar Series SBIRT Curricular Resources: Level 2 Webinar #3 October 16, 2015 Richard D. Blondell, MD Shannon Carlin-Menter, PhD Urmo Jaanimägi (Supported by a grant from the Conrad N. Hilton Foundation to the American Board of Addiction Medicine Foundation)

2. 2015 -2016 SBIRT Milestone Webinar Series July 17: Baseline August 21: 1 st Quarter October 16: 2 nd Quarter February 19: 3 rd Quarter May 20: Final Evaluation 2

3. 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

4. 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

5. 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

6. SBIRT Milestone ONGOING Evaluation Process, Data Collection 6 Program Director Faculty/Staff Fellow Database/System

7. SBIRT Milestone PROGRESS Report, Data Synthesis (Once a Quarter) 7 Program Director Faculty/Staff Fellow Database/System Quarterly Meeting Data Synthesis: Checks boxes on Milestone Report ABAMF(Buffalo)

8. 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.

9. SBIRT Milestones Results 2014-15 Fellows Start of Fellowshi p Baseline Quarter 1 Quarter 2 Quarter 3 Graduation Quarter 4 0.89 2.07 3.05 3.60 4.25 Average SBIRT Milestone Scores by Quarter

10. Curriculum Development 2014-15 Fellows Collected from open-ended Questions Start of Fellowship Baseline Quarter 1 Quarter 2 Quarter 3 Graduation Quarter 4 Reading prior to fellowship Self-study guides/web resources Weekly Didactic Series Readings Roleplays MI Training/Workshops Observations/ Modeling Standardized Patient scenarios Mentoring & Direct Supervision Role Plays & Remodeling Didactics Journal Club on SBIRT Self-guided study Conferences & online training Providing SBIRT in a clinical setting SBIRT Presentations Developing relationships Attending Workshops Roleplays Mentoring Self-Guided study Didactic Sessions ABAM exam Research Article Collaborations

11. Feedback & Assessment 2014-15 Fellows Word Cloud

12. Fellow Self-Reflections 2014-15 Open-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.”

13. SBIRT Milestones Results 2015-16 Fellows Start of Fellowshi p Baseline Quarter 1 Quarter 2 Quarter 3 Graduation Quarter 4 1.27 * ? No data (only two programs) ? ? ? Average SBIRT Milestone Scores by Quarter * N = 22 Fellows Baseline Response Rates: 22/45 fellows= 49% 12/27 programs= 44%

14. Curriculum Development 2015-16 Fellows Collected from open-ended Questions Start of Fellowship Baseline Quarter 1 Quarter 2 Quarter 3 Graduation Quarter 4 Attended Training Course (SBIRT) Skills Development Session in MI Inpatient Consult Service experience SBIRT Web Resources Readings Direct observation in clinics Teaching session with Residents in Clinic

15. 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.

16. 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!

17. 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

18. GOAL Achieve Milestone Level 3 Level 2Level 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. 18

19. 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 19

20. 20

21. 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) 21

22. Referral to Treatment in Pediatrics (University of Maryland) 22

23. Types of Treatment 23 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)

24. Referral 24

25. Referral 25

26. Referral 26

27. Referral 27

28. 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)

29. 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

30. 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

31. 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. 31

32. Programs Share Previously, Dr. Anna Lembke has agreed to share (program director’s perspective) Others willing to share today? 32

33. Open Discussion 33

34. 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

35. 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. 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