I MPROVING A DOLESCENT H EALTH : F ACILITATING C HANGE FOR E - - PowerPoint PPT Presentation

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I MPROVING A DOLESCENT H EALTH : F ACILITATING C HANGE FOR E - - PowerPoint PPT Presentation

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I MPROVING A DOLESCENT H EALTH : F ACILITATING C HANGE FOR E XCELLENCE IN SBIRT I NFORMATIONAL W EBINAR O CTOBER 30 TH 2:30PM ET C ALL L OGISTICS We recommend calling in on your telephone , but your computer is also an option Remember to

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IMPROVING ADOLESCENT HEALTH: FACILITATING CHANGE FOR EXCELLENCE IN SBIRT INFORMATIONAL WEBINAR

OCTOBER 30TH

2:30PM ET

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  • We recommend calling in on your telephone, but your

computer is also an option

  • Remember to enter your Audio PIN so others can hear you
  • Please mute your line when you are not speaking since we

will have lines open throughout the call

CALL LOGISTICS

This button should be clicked if you’re calling in by telephone. Here’s your audio PIN

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Prefer to write? Type into the question box and click “send.” On the phone? “Raise your hand” and we will open up your lines for you to ask your question to the group.

HOW TO ASK A QUESTION

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TODAY’S PRESENTERS

Molly Molloy, MSW Director of Behavioral Health, Southwest Montana Community Health Center Sharon Levy, MD, MPH Director, Adolescent Substance Use and Addiction Program at Boston Children’s Hospital, Associate Professor in Pediatrics, Harvard Medical School Pam Pietruszewski, MA Integrated Health Consultant, National Council for Behavioral Health

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  • Why SBIRT?
  • Change Package Concepts & Lessons Learned from

the Field

  • Questions & Answers

AGENDA

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4 in 10 high school aged reported past-year alcohol use 1 in 10 reported a binge in the last 3 months

Presenting for general primary care; unpublished data from the AYAM clinic

HEALTH CARE IS AN OPPORTUNITY TO TALK ABOUT

SUBSTANCE USE HEALTH RISKS

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3 in 10 report past-year marijuana use About 1.5 in 10 report using marijuana monthly or more

Presenting for general primary care; unpublished data from the AYAM clinic

HEALTH CARE IS AN OPPORTUNITY TO TALK ABOUT

SUBSTANCE USE HEALTH RISKS

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  • Black outs
  • Unintentional injuries
  • Memory loss

ALCOHOL

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  • Hallucinations (27%)
  • Paranoia/Anxiety (33.6%)
  • Any psychotic symptom (42.9%)

MARIJUANA

Levy S, Weitzman, ER. Acute mental health symptoms in adolescent marijuana

  • users. JAMA Pediatrics. 2018 Dec 17;doi 10.1001/jamapediatrics.2018
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CLINICAL INSTINCTS UNDERESTIMATE SUBSTANCE USE

PROBLEMS

Comparison of Provider Impressions with Diagnostic Interview Medical Provider Impressions Sensitivity Specificity Any use .63 (.58, .69 CI) .81 (.76, .85 CI) Any problem .14 (.10, .20 CI) 1.0 (.99, 1.0 CI) Any disorder .10 (.04, .17 CI) 1.0 (.99, 1.0 CI) Dependence 0.0 1.0

Wilson CR, Sherritt L, Gates E, Knight JR. Are clinical impressions of adolescent substance use accurate? Pediatrics, 2004;114:536-540

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There are no visible signs of substance use or even early problems

Practicing physician “If [patients] are drinking, it’s like stupid high school kids who go out and have a couple beers on a weekend here and there…it’s not like chronic alcohol problems.”

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Did I mention that I was suspended because I showed up drunk to a team dinner?

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Occasionally = once

  • r twice a year

Adults Don’t Use the Same Code…

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Occasionally = Only Fridays and Saturdays

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Official GOP Presidential Job Performance Poll

HOW YOU ASK MATTERS

How would you rate President Trump’s job performance so far?

Great Good Okay Other

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S2BI S2BI: Screening to Brief Intervention

In the past year, how many times have you used:

Tobacco/Nicotine? (such as cigarettes, e-cigarettes, “vapes”)

Never Once or Twice Monthly Weekly or more

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S2BI S2BI: Screening to Brief Intervention

In the past year, how many times have you used:

Alcohol?

Never Once or Twice Monthly Weekly or more

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S2BI S2BI: Screening to Brief Intervention

In the past year, how many times have you used:

Marijuana? (smoked, vaped, edibles)

Never Once or Twice Monthly Weekly or more

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S2BI

In the past year, how many times have you used No substance use

No substance use disorder (SUD)

Mild/Moderate SUD

Severe SUD

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CIDI-SAM interview vs screen frequency item for detecting a substance use disorder

SENSITIVITY/SPECIFICITY OF S2BI

Criterion Standard Dx Screen Frequency Prevalence N (%) Sensitivity (95% CI) Specificity (95% CI)

Any Use Once or twice

90 (42.3) 1 [Reference] 84 (76-89)

Mild/Moderate SUD > Monthly use

41 (19.2) 90 (77, 96) 94 (89, 96)

Severe SUD > Weekly use

19 (8.9) 100 (na) 94 (90, 96)

Levy, S., Weiss, R., Sherritt, L., Ziemnik, R., Spalding, A., Van Hook, S., & Shrier, L. A. (2014). An Electronic Screen for Triaging Adolescent Substance Use by Risk Levels. JAMA Pediatrics. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25070067

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DSM-5 Moderate or Severe Substance Use Disorder diagnosis

S2BI SENSITIVITY/SPECIFICITY

Criterion Standard Dx Sensitivity (95% CI) Specificity (95% CI)

Alcohol Use Disorder 100% 93.6% Cannabis Use Disorder 95.3% 91.6%

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Gryczynski J, Mitchell SG, Schwartz RP, et al. Disclosure of Adolescent Substance Use in Primary Care: Comparison of Routine Clinical Screening and Anonymous Research

  • Interviews. J Adolesc Heal. 2019;64(4):541-543. doi:10.1016/j.jadohealth.2018.10.009

Routine clinical screening (N=5,971) Anonymous research interviewing (N=525) p value n (%) n (%) Reported past year alcohol, marijuana, or other drug use on the CRAFFT prescreen 598 (10.0%) 158 (30.1%) <.001 Screened positive for a substance use problem (CRAFFT score ≥ 2) 246 (4.1%) 92 (17.5%) <.001

Rates of substance use disclosure and positive CRAFFT screening results

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Substance Use Screens documented for patients >12 2018: 21 (1.8%) July-August 2019: 212

PRIMARY CARE PEDIATRICS

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19% 11% 18% 9% 38% 28% 32% 16% 53% 36% 37% 24% 27% 17% 15% 0% 10% 20% 30% 40% 50% 60% Alcohol- Past Year Marijuana- Past Year Any Vaping- Past Year Cigarettes- Lifetime Percent Substance

Monitoring the Future Study & Village Pediatrics: Trends in Prevalence of Various Drugs in 2018

8th Graders 10th Graders 12th Graders Village Pediatrics (avg. age: 16 years) Monitoring the Future 16 year

  • lds
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  • value

TOTAL Counseled for Alcohol Use Asked about alcohol

273 (70.0%) 238 (87.2%)

Not asked about alcohol

117 (30.0%) 60 (51.3%)

Table 1 –Rates of alcohol counseling by screening status

Lunstead J. NIAAA screening and counseling brief report. Journal of Adolescent Health. 2019. In press.

Screening may encourage counseling

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  • value

TOTAL Counseled for Alcohol Use Asked about alcohol

273 (70.0%) 238 (87.2%)

Not asked about alcohol

117 (30.0%) 60 (51.3%)

Table 1 –Rates of alcohol counseling by screening status

Lunstead J. NIAAA screening and counseling brief report. Journal of Adolescent Health. 2019. In press.

Screening may encourage counseling

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AAP SBIRT GUIDELINES

Use validated screening tool to identify risk level and appropriate intervention

Brief Health Advice Brief Intervention Positive reinforcement Referral to Treatment

Abstinence Substance use without a disorder Mild/moderate substance use disorder Severe substance use disorder

Levy SJ, Williams JF. Substance use screening, brief intervention, and referral to treatment. Pediatrics, 2016;138(1):e20161211.

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MENTAL HEALTH CARE USE OVER 3 YEARS AFTER ADOLESCENT SBIRT

Sterling S, Kline- Simon AH, Jones A, Hartman L, Saba K, Weisner C, Parthasarathy

  • S. Health Care

Use Over 3 Years After Adolescent

  • SBIRT. Pediatr.

2019 May.

1 y Postindex 3 y Postindex SBIRT (N=1255) Usual Care (N=616) P SBIRT (N=1255) Usual Care (N=616) P

n

% n % n % n % Use

  • Primary care visit

315 25.1 163 26.5 − 1036 82.5 520 84.4 −

  • Substance use visit

5 0.4 1 0.2 − 26 2.1 23 3.7 −

  • Psychiatry visit

66 5.3 39 6.3 − 235 18.7 128 20.8 − Comorbidity

  • Mental health diagnosis

85 6.8 57 9.3 − 341 27.2 189 30.7 −

  • Substance use

diagnosis 11 0.9 6 1.0 − 83 6.6 66 10.7 ***

  • Chronic conditions

68 5.4 48 7.8 *** 396 31.6 201 32.6 −

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INTRODUCING!

The change package is available to the public for free at: ySBIRT.org

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THE DISTANCE BETWEEN THEORY AND PRACTICE …

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…IS FURTHER IN PRACTICE THAN IN THEORY

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2007 2008 2009 2010 2011 2012 2013 2014 2015

Guidelines help to change behavior

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200 7 200 8 200 9 201 201 1 201 2 201 3 201 4 201 First survey administered Second survey administered 2007 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 2017 Third survey administered

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ANNUAL SCREENING RATES

1) American Academy of

  • Pediatrics. Periodic Survey of

Fellows #31: Practices and Attitudes Toward Adolescent Drug Screening. Elk Grove Village, IL: American Academy of Pediatrics, Division of Child Health Research; 1997. 2) Harris et al. Results of a statewide survey of adolescent substance use screening rates and practices in primary care. Subst Abus. 2012;33(4):321-326. 3) Levy et

  • al. Screening Adolescents for

Alcohol Use: Tracking Practice Trends of Massachusetts

  • Pediatricians. J Addict Med.

2017;11(6):427-434. 4) Levy et al, JAM. Screening Adolescents for Alcohol or Other Substance use in Massachusetts, in press.

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VALID SCREENING TOOL USE

Levy et al, JAM. Screening Adolescents for Alcohol or Other Substance use in Massachusetts, in press.

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RESPONSE TO POSITIVE SCREEN

Levy et al, JAM. Screening Adolescents for Alcohol or Other Substance use in Massachusetts, in press.

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BARRIERS TO FOLLOW-UP

P=.04 P=.04

Levy et al, JAM. Screening Adolescents for Alcohol or Other Substance use in Massachusetts, in press.

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BARRIERS TO SCREENING

P=NS

Levy, et al. Screening Adolescents for Alcohol Use: Tracking Practice Trends of Massachusetts Pediatricians. J Addict

  • Med. 2017;11(6):427-434.
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  • SBIRT improves clinical outcomes
  • Implementation practices matter!
  • Guides and toolkits improve practice

SUMMARY

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DEVELOPMENT: PRACTICE TRANSFORMATION TEAM

  • Henry Chung, MD—Montefiore Care Management, Team Chair
  • Sharon Levy, MD, MPH—Harvard Med School, Boston Children’s Hosp, Team Chair
  • Maria Dolores Cimini, PhD—State University of New York at Albany
  • Holly Hagle, PhD—Addiction Technology Transfer Center
  • Thomas E. Freese, PhD—UCLA Integ Substance Abuse Programs
  • Howard Padwa, PhD—UCLA History & Social Studies of Medicine Program
  • Marla Oros, RN, MS—Mosaic Group
  • Stacy Sterling, DrPH, MSW, MPH—Kaiser Permanente
  • Carolyn J. Swenson, MSPH, MSN, RN—SBIRT Colorado
  • Community Health of South Florida, Inc.
  • Corporación SANOS, Inc
  • Delhi Community Health Center
  • Family First Health
  • Health Services Inc
  • Jordan Valley Community Health Center
  • MHC Healthcare
  • Pillars Community Health
  • Project Vida
  • Southwest Montana Community Health Center
  • Venice Family Clinic
  • Vista Community Clinic

FIELD TESTING: PILOT SITES

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  • Mission: To inspire hope and empower wellness by providing access to

comprehensive healthcare

  • 12,804 patients served
  • 55,000 patient visits
  • 77% of patients are low income
  • Sites in 4 counties
  • 9 sites including special partnerships
  • Butte Head Start
  • Butte Local Jail
  • Butte Homeless Shelter
  • Butte Pre-release program
  • Child Evaluation Center
  • SMART
  • Rural & Frontier – Access: 12,241 square miles covered

SOUTHWEST MONTANA COMMUNITY HEALTH CENTER

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  • 1. Use the S2BI to screen for

substance use risks in adolescents

CHANGE CONCEPTS: SCREENING

  • 2. Ensure capacity for

evidence-based response based on screen results

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  • Developing comfort in asking the questions about

drug and alcohol use

  • Develop workflow
  • Considerations for training
  • Follow through on positive screens

LESSONS LEARNED FOR SCREENING

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  • 1. Communicate age-appropriate risks to

health and well-being if any past year use

  • 2. Leverage primary care team-patient

relationship

  • 3. Ensure primary care team members

receive BI training tailored to defining risk and developmental level

CHANGE CONCEPTS: BRIEF INTERVENTION

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  • Training all staff in MI
  • Combating belief that a brief intervention will lengthen appointments
  • It’s brief – 1 minute, 5 minutes – BRIEF
  • Risk Reduction
  • Warm hand-offs to behavioral health when needed
  • Workflow for documentation of anticipatory guidance, abbreviated BI

and BI

LESSONS LEARNED FOR BRIEF INTERVENTIONS

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  • 1. Establish criteria for referral
  • 2. Develop protocol and procedures to link

patients to care, leveraging provider/organizational partnerships

  • 3. Ensure capacity, protocols, and

documentation standards for ongoing care management (interim management, supporting readiness, facilitating treatment entry and follow-up)

CHANGE CONCEPTS: REFERRAL TO TREATMENT

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  • Provide proper training for BH providers that are not dually

licensed but can still do Level 1 treatment for SUD

  • If there are no LAC’s on staff, is there a community partnership

that can be formally partnered with through contracting services

  • Can contracted services be added at your actual site so patient does not

have to receive care elsewhere

  • Most importantly, make sure that the PCP teams know how and

who to refer to when patients meet criteria for referral

LESSONS LEARNED FOR REFERRAL TO TREATMENT

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  • 1. Organizational needs self-assessment
  • 2. Identify and develop sustainable financing strategy including

policy, reimbursement, existing service incentive programs

  • 3. Maximize data collection and utilization strategy, including use of

electronic medical records, to translate data into action and foster continuous quality improvement

CHANGE CONCEPTS: OPERATIONAL SUSTAINABILITY

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  • Change – Change fatigue
  • Integrating into the entire clinic
  • Normalizing the conversation for all patients about how

substance use impacts daily living and health conditions

  • Having a true champion who can drive the project forward

LESSONS LEARNED FOR OPERATIONAL SUSTAINABILITY

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QUESTIONS?

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Please contact Stephanie Swanson: StephanieS@Thenationalcouncil.org

RESOURCES, TRAINING & CONSULTATION

Available at: ySBIRT.org Available at: thenationalcouncil.org