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SMART Choices Learning Collaborative Kick-Off Meeting

March 22, 2019

Agenda1:00 to 2:30 p.m.Welcome, Introductions to StaffShannon Meyers (Mikita), RN; Megan Tobin, RN, BSN; Victoria Winkeller, MD

Introduction to the Learning Collaborative StructureShannon Meyers (Mikita), RN

Introduction to SBIRTVictoria Winkeller, MD; Megan Tobin, RN, BSN

2:30 to 2:45 p.m. Break

2:45 – 4:00 p.m.Feedback, Listen, Options (FLO)Victoria Winkeller, MD; Megan Tobin, RN, BSN

4:00 – 5:00 p.m.Brief Intervention Role-PlayAbigail Schlesinger, MD; Shannon Meyers (Mikita), RN; Megan Tobin, RN, BSN; Victoria Winkeller, MD

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Megan Tobin, RN, BSN

Victoria Winkeller, MD

Shannon Meyers (Mikita), RN

Abigail Schlesinger, MD

Expertise: IHI, Kognito, The Danya InstituteFunding: CVS, PA State, Conrad N. Hilton Foundation

Introductions

SMART Choices = SBIRT

ScreeningMotivational InterviewingAndReferral toTreatment

ScreeningBriefInterventionReferral toTreatment

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What is a Learning Collaborative?

Structured approach for

change

Adopt best practices in

multiple settings

Uses adult learning

principles & techniques

Time-limited learning process

Shared learning & collaboration

IHI Model

• Proven quality improvement record

• Supports skill development of clinical staff

• Promotes mutual learning among participants

• Increases use of data to inform decisions and practice

• Develops infrastructure to sustain improvement

• Changes the culture of the practice

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SMART Choices Learning Collaborative Mission

Use Screening, Brief Intervention, and Referral to Treatment (SBIRT) to improve access to screening, early intervention, and treatment services for all adolescents with or at risk for substance use disorders (SUDs) regardless of insurance type.

Support providers in a quality improvement effort to operationalize and implement best practices for SBIRT.

Each Quality Improvement Team (QIT) will identify a lead clinician to be the champion and a train the trainer model will be implemented within each practice.

SMART Choices Learning Collaborative Mission

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SMART Choices Learning Collaborative Charter

Facilitators will do the following:

• Provide experts to teach and coach participants

• Guide the work through monthly webinar-style coaching calls

• Establish aims against which to measure the impact of quality improvement efforts, track each organization’s progress toward the stated aims, and provide feedback

• Evaluate the overall impact of the quality improvement effort both at the organizational level and for the entire collaborative

Participants will do the following:

• Establish an internal leadership team (Quality Improvement Team)

• Will identify a lead clinician to be the champion

• Implement SBIRT

• Commit to full participation in face-to-face meetings and monthly coaching calls between February 2019 through February 2020

• Overall participation involves:• 2 more face-to-face meetings within a year (August 2019 & February 2020)• Monthly calls, 1 hour per call

SMART Choices Learning Collaborative Charter

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2019 - Year 3

2017 – Year 1• CCP Bass Wolfson• CCP Pittsburgh Pediatrics• CCP Moon, Wexford, South Fayette

2018 – Year 2• CCP Bedford• CCP SHPA• Primary Care Center

2019 – Year 3Group 1• Staunton Clinic• Mon Yough• CCP Armstrong• CCF• BHA Altoona

Group 2• CCP Waterdam, South Hills• CCP Bellevue

Process Aims

By March 2020, 100% of youth, between the ages 11-20 years, are screened for substance use

By March 2020, 100% of youth with monthly or more substance use, receive a Brief Intervention

By March 2020, 100% of youth who used a substance once or twice, receive Brief Advice

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Learning Collaborative Structure

Facilitators Producer Faculty

Project Support & Oversight Outcomes

Learning Collaborative Process

Establish a process for continuous QI

Use of information• Process, milestones, and

progress (implementation)• Outcomes (impact)• Plan, Do, Study, Act (PDSA) cycles

Feedback and support• Monthly support calls• Learning sessions

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PDSA Cycle

• Plan-Do-Study-Act

• Small tests of change

• Conduct one or more each month

• Measure impact of small test of change

• Review in monthly collaborative calls

PDSA Example

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PDSA Example

PDSA Example

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Screening

Brief Intervention

Referral to Treatment

Introduction to SBIRT

Screening

BriefIntervention

Referral toTreatment

Identify patients at risk for substance use disorders using standardized screening tools.

Engage a patient showing risky substance use behaviors in a short conversation, providing feedback and advice.

Provide a referral to specialized substance use treatment services, when needed.

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Screening Tools

CRAFFT• Recommended by the American Academy of Pediatrics• Screens for risks related to substance use• Predicts probability of a substance use disorder

Screening to Brief Intervention (S2BI)• Developed at Boston's Children's Hospital with support from NIDA• Validated for use with adolescents• Screens for type and frequency of substance use

CRAFFT

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INTERVENTION DECISION TREE

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Screening

Assessment

PreventativeServices

(Action Plan)

Goal: Delay or preclude chronic condition

Screening Does Not Provide a Diagnosis

Assessment is the Next step of Screening

RED FLAGS

1. Binge episodes2. Use while driving(either while they are driving

or someone else)3. Injecting drugs4. Mixing drugs5. High risk behaviors/danger while using6. Daily or almost daily use of any drug

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Binge Drinking Levels for Youth

BOYS GirlsAges 9-13 ---- 3 drinks 9-17 ---- 3 drinksAges 14-15 --- 4 drinks 18+ ----- 5 drinksAges 16+ ------ 5 drinks

How Teens Really Drink

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Abstinence

Addiction

Responsible Use

Traditional Continuum of Substance Use

SBIRT Model: Continuum of Substance Use

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Abstinence

Experimental Use

Binge Use

Abuse

Substance Use Disorder

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Brief Advice & Brief Intervention

Referral to Treatment

Brief Advice or Brief Intervention

Positive Reinforcement

Brief Advice vs. Brief Intervention

Brief Advice – medically-based advice about the health consequences of substance use, strengths-based approach emphasizing the patient's strengths and the possible impact of his or her substance use

Brief Intervention – non-judgmental, non-confrontational conversation, using Motivational Interviewing (MI) to enhance a patient's motivation to change his or her substance use

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Brief Advice Example

The “BI” of SBIRT

• The natural “next step” after screening

• Incorporates the “Spirit of MI”

• Fundamentally the opposite of advice-giving

• Requires roles of healthcare provider and patient to shift

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Spirit of Motivational Interviewing (MI)

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Sustain Talk (Anti-Change)

• “I love how smoking weed makes me feel.”

• “It’s not a big deal to have a few beers with my friends”

• “My boyfriend would break up with me if I stopped drinking”

• “Smoking helps me relax”

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Change Talk (Pro-Change)

• “I didn’t like it when I got really drunk.”

• “I know drinking is not good for me.”

• “I don’t play soccer as well after I have a drink.”

• “My mom would be disappointed if she found out.”

Confidentiality

• ADOLESCENTS• have a right to a confidential conversation about substance use

• BUT• Confidentiality should be broken when there is a concern

about the safety of a child or adolescent

• UNFORTUNATELY• Most situations are not as clear cut as acute danger

• AND• There is evidence to support that the involvement of parents

can improve outcomes(with caveats related to the family unit)

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General Guidelines for Informing Parents

Any substance use Some mild problems Significant problems or probable dependence

ElementarySchoolAges 9 - 11

YES YES YES

Middle SchoolAges 11 - 14 MAYBE YES YES

High SchoolAges 14-18 MAYBE MAYBE YES

Derived from NIAAA Guidelines

Questions?

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Video 1

What went well?

What went wrong?

Brief Intervention

• Brief

• Cost-Effective

• Minimizes resistance

• Long-term harm reduction

• Patient is the expert, not the healthcare professional

• Respects patient autonomy

• Non-judgmental attitude

Benefits Challenges

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Goal of Brief Intervention:Negotiate behavior change to reduce substance use.

Brief Intervention Should “FLO”

F

Feedback•Make a simple, factual statement about risk,

then pause

LListen• Prompt patient to “think out loud,” listening

curiously

OOptions• Encourage expanded thinking about

alternatives

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Feedback

Introduce the topic

Signal transition to collaborative process by asking permission

Disclose concern and explain rationale

Introduce the topic

“I would like to talk a bit about the results of the screening you filled out in the

waiting room."

"Is that okay with you?”

Signal transition to collaborative process by asking permission

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Disclose concern and explain rationale

"I'm concerned that you are drinking alcohol monthly. I've seen bad things happen to teens when they drink. I don't want anything bad to happen to you."

Expect Resistance

• Use “universal precautions” against opposition

• Resist the urge to debate or “lecture”

• Try linking the problem to their reason for visit

• Pausing for a moment often leads patients to elaborate on their initial statement

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Brief Interventions Should “FLO”

F

Feedback•Make a simple, factual statement about risk,

then pause

LListen• Prompt patient to “think out loud,” listening

curiously

OOptions• Encourage expanded thinking about

alternatives

Listen

Patient does the talking

Provider keeps conversation focused with prompts and general direction

Use active listening to convey respectful collaboration

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Patient does the talking

"I’d like to hear your thoughts on..."

"On one hand, you enjoy drinking with your friends and on the other hand, your grades are suffering. What do you think you'll do

about that?"

Provider keeps conversation focused with prompts and general direction

“I’m not going to push you to change anything you don’t want to change,

but I wonder if there's a way that you can keep your friends and get A's too."

Use active listening to convey respectful collaboration

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Things to Listen For

• Ambivalence – desire to change

• Importance – need to change

• Confidence – ability to make a change

• Options – ideas for taking action

Brief Intervention Should “FLO”

F

Feedback•Make a simple, factual statement about risk,

then pause

LListen• Prompt patient to “think out loud,” listening

curiously

OOptions• Encourage expanded thinking about

alternatives

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Options

Tasks the patient identifies as the ones they are most ready to address

Specific, relevant, and realistic

Planning to reduce harm does not necessarily condone substance use

Tasks the patient identifies as the ones they are most ready to address

"What do you see as your options?"“I could tell you what has worked for other people, if

you’d like.”

"So it sounds like you are going to start going to parties 1 day a week instead of 2 days a week. That will give you more time to work on homework and

improve your grades."

Specific, relevant, and realistic

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"Let's think about a way for you to get home safely after a party. Do

you have a friend or family member that can pick you up instead of

driving home yourself?"

Planning to reduce harm does not necessarily condone substance use

Measure Motivation

• Use rulers to determine importance, confidence, and readiness for change

• Ask why they didn’t choose a lower number to help them reinforce their own motivation

• Ask what it would take to increase by 1 to identify motivating factors

• Ask what a higher number would look like to translate motivation into behavioral terms

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Assess Confidence for Change

• “On a scale of 1-10, how confident are you in your ability to change your substance use?”

• “Why did you choose a 7, and not a lower number like a 5?”

1 2 3 4 5 6 7 8 9 10

Assess Readiness for Change

• “On a scale of 1-10, how ready are you to change your substance use?”

• “Why did you choose a 3, and not a lower number like a 1?”

• “What does a 4 look like to you?”

1 2 3 4 5 6 7 8 9 10

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Action Plan

• Elicit options from patient

• Offer guidance

• Affirm autonomy and strengths

• Provide relevant educational materials• teens.drugabuse.gov

Developing a Goal

• Identify a pertinent, attainable goal

• What the patient wants to do, notwhat you think they should do

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Assure Follow Up

• Following up reinforces the importance of making a change

• Follow ups are flexible• Phone call• Nurse outreach• Return visit

Giving Advice is OK if…

• It is something the patient doesn’t already knowand

• You have permission from the patientand

• It is going to be helpful to the patient

Give Advice When…

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Referral to Treatment

• Brief intervention still can be used with the highest risk patients

• Aim intervention at accepting referral to treatment rather than trying to change on their own

• https://findtreatment.samhsa.gov/

• SAMHSA Help Line 1-800-662-HELP (4357)

Video 2

What went well?

What went wrong?

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• Efficacy and effectiveness demonstrated in as little as 3-5 minute interventions

• Key is shifting the way you communicate with patients

• Simple, not easy (remember, change is hard!)

A Little Goes a LONG Way!

Questions?

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• Break up into groups

• Role play scenarios to practice BI

• Use the resources you have for help!

Now for Practice

Patient Scenarios

McKenzieAge: 18

McKenzie presents to your office unaccompanied. She endorses feeling depressed for about 3 weeks.

AvaAge: 16Ava presents to your office with her mother. Mom reports declining grades and irritability.

SophiaAge: 13Sophia presents to your office with her mother. Mom reports finding a juul and an empty beer can under Sophia's bed.

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Monthly phone calls start in April 2019Date & time TBDYou will receive a series of invitations via emailSkype for BusinessNeed connection to phone and internetAt least 1 QIT member should attend each monthly call

WorkbooksDue 2 weeks prior to monthly callsEmail completed workbooks to call facilitatorsWe will explain how to complete workbooks during a webinarThis webinar will be part of the first monthly call (April 2019)

Next Steps

Questions?