INTEGRATED CARE CONFERENCE 2019 CHLA EMERGENCY DEPARTMENT & - - PowerPoint PPT Presentation

INTEGRATED CARE CONFERENCE 2019 CHLA EMERGENCY DEPARTMENT & SBIRT- SUBSTANCE USE PREVENTION & TREATMENT APPROACHES FOR ADOLESCENTS & YOUNG ADULTS OCTOBER 24, 2019

CHRISTINA ESQUIBEL, CATC-I - BRETT MCGILLIVRAY , LCSW - IRENE LIM, LCSW

Disclaimer

CHLA has no relevant financial relationships with the manufacturer(s) or any commercial product(s) and/or provider of commercial products or services discussed in this CME/CE activity. We do not intend to discuss unapproved/investigative use

• f commercial product(s)/device(s) in this presentation.

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Learning Objectives

• 1. Learn how a screening tool can be used as a way to develop

rapport.

• 2. Describe how SBIRT is implemented at CHLA Emergency

Department (ED)

• 3. Demonstrate the importance of interdisciplinary flexibility

needed when working with an Emergency Department.

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Substance Use Prevention & Treatment Program

• At the Division of Adolescent and Young Adult Medicine

(DAYAM)

• Funded by LA County Department of Public Health, Substance

Abuse Prevention and Control Department and SAMHSA

• At-Risk and SUD Treatment services for youth and young

adults ages 12-25

• Walk-in clinic on Tuesdays, 8:30am – 11:00am
• 5000 Sunset Blvd. 7th Floor, Suite 701, LA, CA 90027

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• Located on the ground floor of the Main Hospital
• Level I Trauma Center (1 of 2 in LA County)
• Cannot deny service to anyone
• Not for Profit Hospital
• 4650 Sunset Blvd. Ground Floor, LA, CA 90027

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CHLA Emergency Department

Programs at DAYAM

• Teenage and Young Adult Health Center
• Substance Use Prevention and Treatment
• Training, Research and Community Engagement Program
• Project NATEEN – for expectant and parenting teens
• Homeless Adolescent Wellness Clinic
• HIV Prevention and Treatment Program
• Center for Transyouth Health and Development
• Behavioral Health Program

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SAMHSA TREE Design

• Integrate SUD & CHLA ED more

intentionally

• Work with 2 local high schools
• Outpatient SUD services for

youth/young adults

• Youth Leadership development
• Intergenerational family support

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3,000+

• verdoses/ingestion

coming through ED annually 382 patients admitted through the ED daily Not enough resources for

• utpatient AOD

Counseling

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CHLA Level 1 Trauma Center

Demographics of SUPT Youth

76% 20% 1% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Drug of Choice

Marijuana Alcohol Hallucinogens Benzodiazepines Methamphetamine Inhalants Other Illegal Drugs Cocaine/Crack Heroin Morphine Percocet Codeine OxyContin Methadone Ketamine Tranquilizers 8

*GPRA 18-19

Demographics of SUPT Youth

63% 37%

Gender

Male Female 9

Demographics of SUPT Youth

82% 9% 7%2%

Ethnicity

Latino African American Caucasian Other 10

Demographics of SUPT Youth

34% 29% 14% 12% 11%

Other Characteristics

Trauma Probation Homeless Pregnant DCFS 11

Objective 1

Learn how a screening tool can be used as a way to develop rapport.

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Screeners used in ED

• Distress Response Survey

(Blue Triangle)

• CRAFFT
• S2BI

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Systems collide?

Emergent Medical Environment Therapeutic Environment

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Blue Triangle and Confidentiality

Distress Response Survey (Blue Triangle)

• Do you feel like hurting/killing yourself/others?
• Do you drink alcohol or use drugs often or a lot?
• Do you frequently feel sad, down or depressed?
• Anyone touch private parts/you didn’t want them to?
• Hit with anything so hard it left a bruise/mark?
• Do you hear/see thing other people cannot see/hear?
• Do you often feel upset, anxious and nervous?
• Seen your parents hit/use objects to hurt the other?
• Awful thing happened affected you physically or emotionally?
• Have you ever been bullied or bullied someone?

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Screening Tools

Car, Relax, Alone, Forget, Family/Friends, Trouble

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S2BI

SUD Services in CHLA ED

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When is the SUD counselor called into the ED?

Preparing for S2BI

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Confidentiality/ Sensitive Services

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“A minor who is 12 years of age or older may consent to medical care and counseling relating to the diagnosis and treatment of a drug or alcohol related problem.” Cal. Fam. Code §6929(b)

California minor consent and confidentiality laws: Minor consent and when parents may access related medical information, http://www.publichealth.lacounty.gov/dhsp/Providers/toolkit2.pdf

Minor Consent

Discretion to Inform Parents without Minor’s Consent? Providers may not disclose information to parents without a minor’s written authorization. However, an exception allows a program to share with parents if the program director determines the following three conditions are met: (1) that the minor’s situation poses a substantial threat to the life or physical wellbeing of the minor or another; (2) that this threat may be reduced by communicating relevant facts to the minor’s parents; and (3) that the minor lacks the capacity because of extreme youth or a mental or physical condition to make a rational decision on whether to disclose to their parents. 42. C.F .R. 2.14.

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Parental Vignette

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Objective 2

Describe how SBIRT is implemented at CHLA Emergency Department (ED)

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Screen

• BLUE TRIANGLE
• S2BI
• CRAFFT

Brief Intervention

• Positive

reinforcement

• Express

concern and explore Referral to Treatment

• Warm hand off

What is SBIRT?

Endorsed by: American Medical Association, National Institute Of Health, American College Of Surgeons, Federation Of State Medical Boards, SAMHSA, NIAAA, Office Of National Drug Control Policy, World Health Organization

Goals Of Brief Intervention

• To increase awareness of the problem
• To increase motivation to change
• To create behavior change

➢ Brief interventions trigger change ➢ A little counseling can lead to significant change, e.g., 5

minutes has same impact as 20 minutes

PRE-SCREEN @ CHLA ED Blue Triangle

• Ex: “Do you drink alcohol or use drugs often or a lot?”
• “No”: Screening is complete*
• “Yes”: Social Work is called, then SUD Counselor

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Questions/Answers

• Provider: “So tell me what brings you in to the ED

today?”

• Client: “I thought that vaping was safer than weed

because you can’t smell it. So I tried it and I think I had too much. I just wanted to try it like everyone else.”

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S2BI

Positive Reinforcement

Transitional Statement “Thank you for being honest about what happened to you. Based on what you told me, it sounds like you thought vaping was safer but you took too much. I think that it’s great that you want to be safer.” Can I give you more information about vaping?”

• Provider: “Thank you for letting me talk to you about vaping. Tell

me what you’ve heard about vaping in the news recently? Or what you know about it?”

• Client responds….

Provider provides education and positive reinforcement. Education may include recent info, a handout, discussion about commercials, social media, etc..

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Brief Intervention

Referral to Treatment

• Client: “Yeah, I started drinking last year. I’m not sure why I

blacked out. I’m not doing very well in school and my mom never trusts me anymore.”

• Client: “I drink all of the time. I’m not sure why I blacked out this
• time. It’s not a big deal.”
• Client: “I smoke everyday but it doesn't effect me. But I don’t

want it to get worse.”

Transitional Statement - “Thank you for being open and honest with

• me. Based on what you told me about your use, it sounds like you

might have some consequences happening like being here in the

• Emergency. I’m going to recommend that you come in so we can

talk about this further. What do you think about that? I can give you letters and deal with school as well as help educate your parents on some of the struggles you're dealing with. Would you like to talk more about it?

Referral to Treatment

Warm Hand Off

• Describe options based on

available services

• Facilitate hand-off by

connecting youth with appropriate treatment provider

• What else can be done?

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“Brief advice from a primary care provider has shown to significantly decrease initiation of drinking and increase cessation rates for alcohol and marijuana use among adolescents.”

Massachusetts Department of Public Health Bureau of Substance Abuse Services, Provider Guide March 2009

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Many health care providers feel they:

• Don’t have the tools
• Don’t have the training
• Don’t have resources
• Don’t have the time

Objective 3

Demonstrate the importance of interdisciplinary flexibility needed when working with an Emergency Department.

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Collaborative Vignette

Champagne Vignette

• 16yr old complains of nausea and stomach pains
• Patient tests negative for AOD on Distress Response

Survey (🔽)

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Multi-Disciplinary Vignette

Reality Testing

“My use isn’t a problem” “This isn’t a big deal”

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Elements of MI

• Express Empathy – “Sounds like you had a difficult day”
• Develop Discrepancy – “Part of you really wants to explore

things but you didn’t really know how much to use”

• Roll with Resistance – “So, you really think your mom is going

to be disappointed if she knew the truth”

• Support Self-Efficacy – “You were able to ask for help when

you realized you took too much”

Simple Reflection

Example: Youth was found down at school she comes in admits to medical staff of taking 3 Xanax Adolescent: I just wanted to feel a part of something. Everyone at school is always doing it and I thought is was safer than smoking weed. I see girls do it all the time. I didn’t know I could take too much of it. I’m sad my mom will be disappointed in me. Simple Reflection: (Repeat)

• So you feel like connecting with people at school is important to you.
• But then you didn’t realize that too much could put you in the hospital
• It sounds like you really want your mom to be proud of you.

Techniques

• Unconditional Positive Regard
• Do not confront or “break down” defenses
• Emphasize youth’s control over self
• Listen to listen
• Offer flexibility
• Consistency
• Make your time count
• Provide empathy and acknowledge youth’s experience of

being in an ED

Lasting Effects

• Increased referrals from other parts of the hospital.
• All disciplines requesting consults, trainings and

referrals.

• Value of SU services – early intervention and SUD.
• Increase in successful warm referrals and linkages to

Adolescent/Young Adult care

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Resources

• Los Angeles County Substance Abuse Service Helpline SASH:

(844) 804-7500

– Toll-free for both youth and adults – Open 24/7/365 – Screening and referral services

• Crisis Text Line

– Text CONNECT to 741741 – Available 24/7 – Live, trained Crisis Counselor receives text

• California Youth Crisis Line – (800) 843-5200

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Thank you!

Christina Esquibel – Substance Use Prevention & Treatment cesquibel@chla.usc.edu Brett McGillivray – Emergency Department bmcgillivray@chla.usc.edu Irene Lim - Substance Use Prevention & Treatment ilim@chla.usc.edu

323.361.2450

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• D. Hargraves, C. White, R.Frederick, M. Cinibulk, M. Peters, A. Young & N. Elder. (2017). Implementing

SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: lessons learned from a multipractice evaluation portfolio. Public Health Reviews (2017) 38:31 T . Ozechowski, S. Becker , & A. Hogue. (2016) SBIRT-A: Adapting SBIRT to Maximize Developmental Fit for Adolescents in Primary Care. J Subst Abuse Treat. 2016 March; 62: 28–37. Slemon, E. Jenkins, R. Haines-Saah, Z. Daly & S. Jiao (2019). “You can’t chain a dog to a porch”: a multisite qualitative analysis of youth narratives of parental approaches to substance use. Harm Reduction Journal (2019) 16:2 Center for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2017. Morbidity and Mortality Weekly Report, Surveillance Summaries. Vol. 67. No. 8. June 15, 2018 Substance Abuse and Mental Health Services Administration, https://www.samhsa.gov/ National Institute on Drug Abuse, https://www.drugabuse.gov/news-events/news- releases/2017/11/nida-launches-two-adolescent-substance-use-screening-tools

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Sources