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Webinar:Innovations in Screening, Brief Intervention &
Substance Use Education for Health Professionals
February 25, 2015, 3-4pm ET
Agenda:1) Challenges and best practices in conducting SBIRT (15 min)
2) Benefits of using virtual humans in the development and assessment of SBIRT (5 min)
3) Demo of At-Risk in Primary Care + Research results (15 min)
4) Overview of SAMHSA’s SBIRT RFA (5 min)
5) Q&A (10 min)
Dr. Eric GoplerudSVP and Director Public Health DepartmentNORC at the University of Chicago
Dr. Tracy McPhersonSenior Research ScientistPublic Health DepartmentNORC at the University of Chicago
Ron GoldmanCo-Founder & CEOKognito
SBIRT Implementation, Benefits, and Challenges:Opportunities to Enhance Implementation and Training using
Technology
Tracy L. McPherson, PhDNORC at the University of Chicago
Presenter
Tracy L. McPherson, PhDSenior Research ScientistPublic Health Research NORC at the University of Chicago National SBIRT ATTCBIG SBIRT InitiativeAdolescent SBIRT SW & Nursing Learning [email protected]@gmail.com
Agenda
Why SBIRT? Implementing SBIRT Challenges Hot spots Training Challenges, Opportunities, and
Resources Conrad Hilton Adolescent SBIRT Project
Why SBIRT?Substance use is a public health and safety issue.
Substance use has a profound impact on patients/clients and their families:• Cause or exacerbate health conditions• Poorly managed health conditions• Reduce effectiveness of medications• ER visits and excess hospital stays• Accidents and damage• Injuries and violence• Lower productivity, lost work days• Worker compensation , disability, worker turnover• Financial and legal problems• Family disruptions and relationship problems• Sexual risk-taking• Overdose and suicide
Why SBIRT?
0 5 10 15
Iron deficiency
Unsafe sex
Illicit drugs
inactivity
Low fruit & Vege …
Overweight
Cholesterol
Alcohol
Blood pressure
Tobacco
Percent of disability-adjusted life yearsNorthwest ATTC iThur presentation: (2012) The World Health Report 2002
SBIRT Provides a Framework for Addressing 3 of the 10 Leading Risk Factors for Disease In Developed Countries
Why SBIRT? SBIRT is a comprehensive, integrated, public health approach to the
delivery of early intervention and treatment services for people with substance use disorders and those at-risk for developing them.
Why SBIRT?
Why SBIRT?SBIRT Aims To:
• Increase early identification of patients/clients at-risk for SU problems.
• Build awareness and educate patients/clients on U.S. guidelines and risks associated with SU.
• Motivate those at-risk to reduce unhealthy, risky SU; and adopt health promoting behavior.
• Motivate individuals to seek help and increase access to care for those with (or at risk for) a SUD.
• Foster a continuum of care by integrating prevention, intervention, and treatment services.
Source – SBIRT Oregon Residency Program, 2012
In a nutshell: Why SBIRT?At-risk drinking and alcohol problems are common
SBIRT is proven to be effective
SBIRT
Implementing SBIRT
• Primary care• Trauma• Emergency Department• Hospital Inpatient• Employee Assistance Programs• Health Promotion and Wellness
Programs• Occupational Health and
Safety, Disability Management• Community Mental Health
Centers
• Federally Qualified Health Centers• Drug Courts, Juvenile Justice• Dental Clinics• HIV Clinics• Colleges/Universities• School-based Health Centers• Peer Assistance Programs• Addiction Treatment• Counseling/Therapy• Health Professional Training Programs
SBIRT can be implemented in a range of settings:
Hot Spots of SBIRT Implementation
Hot Spot 1: Hospitals
Screening and Treating Acutely Ill and Injured Patients with Comorbid Substance Use
Cochrane Collaboration review (McQueen et al, 2011) 14 RCTs, adults and adolescents
Outcomes favor BI over non-treatment controls• Significant drop in 6 month alcohol consumption • Significant drop in alcohol consumption at 9 months• Self Report at 1 year favor BI• Significantly fewer deaths at 6 months and 1 year
Salina Regional Health Center
• 199 Bed Acute Care Regional Health Center-Level III Trauma Center
• 27,000 ED presentations per year• Alcohol/Drug DRG was 2nd most
frequent re-admission
Services provided 24-7 coverage of ED Full time SUD staff on medical
and surgical floors Warm hand off provided to all
SUD/MH services Universal Screening and SBI
beginning in 2013
Outcomes • Re-admission DRG moved from 2nd
to 13th.• 70% of alcohol/drug withdrawal
LOS were 3 days or less.• 83% of SUD patients triaged in ED
were not admitted.• 58% of patients recommended for
further intervention attended first two appointments (warm hand off).
• Adverse patient and staff incidents decreased by 60%.
• CKF detox admissions increased 450% in first year.
• 300% increase in commercial insurance reimbursement.
Hot Spot 2: Prenatal Screening and Case Management
Kaiser –Permanente Northern California’s Early Start Program
• Universal Screening of ALL pregnant women
• Screening questionnaire• Urine toxicology (with consent)
• Place a licensed mental health provider in the department of OB/GYN
• Link the Early Start appointments with routine prenatal care appointments
• Educate all women and providers
A transformational program that is cost beneficial
Rate of Preterm Delivery (<37 Weeks)
8.1%
9.7%
17.4%
6.8%
0.0%
5.0%
10.0%
15.0%
20.0%
SAF SA S Controls
Note: The rate of Preterm Delivery is 2.1 times higher in S group than SAF (Early Start patients)
Maternal and Infant Mean Costs Comparison
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
SAF SA S Controls
Maternal Total Costs Infant Total Costs Maternal and Infant Costs Combined
Positive Screen, No SA Treatment
Hot Spot 3: Youth and Young Adult High Risk Users
Teen and Young Adult School Health and Ambulatory Health SUD Treatment
• Data were pooled from 16,915 adolescents from 148 local CSAT-funded programs and followed quarterly for 6 to 12 months.
• In 2009 dollars, adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake).
• This would be $3.9 Million per 1,000 adolescents served.
• Within 12 months, the cost of treatment was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent.
Hot Spot Webcasts
• Kansas (Substance Use Treatment-Hospital Partnership) http://hospitalsbirt.webs.com/partnershipsimplementing.htm
• Early Start Program at Kaiser (OB/GYN) http://hospitalsbirt.webs.com/hospitalalcoholpregnancy.htm
Hear about other models:
• Gosnold on Cape Cod (Addiction Treatment-Hospital Partnership)http://hospitalsbirt.webs.com/hospitalalcoholpregnancy.htm
• Southwest Virginia Community Health Systems (FQHC) http://hospitalsbirt.webs.com/health-centers-sbirt
• Cook County (Criminal Justice)http://hospitalsbirt.webs.com/criminaljusticesbirt.htm
Challenges of Implementing SBIRT
“We don’t have time. We already do 50 million things…. How can we do one more?”
“We aren’t trained to address substance use and we don’t have the resources to get our staff trained…We can’t take our staff offline.”
“Our patients have more pressing concerns than substance use. It’s not that important compared to the other issues they face like diabetes, heart disease, or depression.”
Challenges of Implementing SBIRT
• Scalability – its not a one size fits all• Facility specific – it does boil down to how will
it work at each site• Common barriers – design specific & site
specific • Training – all settings need initial and
boosters, fidelity and proficiency monitoring in all settings, with all types of practitioners
Common barriers• Lack of awareness, skills, and knowledge about screening tools• Discomfort initiating discussions about AOD use/misuse• Belief of not having enough time to carry out interventions• Uncertainty about referral resources• Limited or lack of insurance company reimbursement
• Negative attitudes toward substance abusers
• Pessimism about the efficacy of treatment
• Fear of losing or alienating patients
• Lack of simple guidelines for brief intervention
• Lack of education and training about the nature of addiction or addiction treatment, and how to effectively screen and intervene
Challenges of Implementing SBIRT
Overcoming Challenges – Prep, Prep, Prep
• Do a strengths assessment• Do a work flow analysis• Define target population• Develop clear practice guidelines• Develop a charting/documentation protocol• Develop a billing strategy• Develop a data collection, storage, and analysis plan• Develop a quality improvement initiative (fidelity/quality)• Establish a referral network• Develop a training plan (get buy-in before you train)• Identify technology to facilitate practice (EHRs, tablets, eSBI)• Identify technology to facilitate training (Interactive simulations, On- Demand
courses/webinars)Don’t recreate the wheel. Identify and use resources and technology that enhance what you’re doing.
SBIRT Training
Face-to-face SBIRT training – Most common
• Often seen as the only or best way• Varies dramatically from a 1 hour didactic presentation to 2+ day workshop• Often a “one shot deal”• One shot deals don’t allow for real world practice and ongoing feedback,
coaching, or booster sessions• May not offer enough observational /vicarious learning• May offer few opportunities practice• May not offer sufficient feedback• Can be costly – to individuals or organizations• Often small training budgets limit the number of staff who can participate• Requires staff to be taken “off line” • May require staff to travel• Must be repeated due to staff turnover
SBIRT Training
Face-to-face training can be enhanced by other learning opportunities:
• Use of actors as standardized patients (can be expensive)• On-Demand courses (often free /low cost; typically
under-utilized/unknown)• Live and recorded webinars - specific settings, populations, or general/
overview (often free/low cost; typically under-utilized/unknown)• Use of e-SBI platforms and tablet-based applications to learn, practice
and facilitate SBI with patients/clients (e.g., Radiant Interactive Behavioral Health Risk Assessment Check-up)
• Use of interactive web-based patient/client simulation technology – allows user to practice competencies and receive feedback, provides boosters/refreshers, assesses skill acquisition (new state of the art technology; typically under-utilized/unknown; e.g., Kognito and MedRespond training)
National SBIRT ATTC – SBIRT Suite of Services
On-Demand Courses
• SBIRT 101 – Foundations Course• SBIRT for Adolescents Course
To access courses go to: http://ireta.org/improve-practice/addiction-professionals/online-courses/
National SBIRT ATTC - Webinar Library
http://my.ireta.org/webinarlibrary-mobile
BIG Initiative – Live & On-Demand Webinars
http://hospitalsbirt.webs.com/webinars.htm http://bigsbirteducation.webs.com/webinars.htm
BIG Initiative – Learner Guides
http://bigsbirteducation.webs.com/learnersguides.htm
Interactive Tablet-based SBIRT ToolsRadiant Interactive – BHRA Check-up
For more information/demo contact Radiant Interactive at [email protected]
Interactive Virtual Patient Simulations - Kognito
More to come on this…
Additional Resources
• SAMHSA-National Council CIHS http://www.integration.samhsa.gov/clinical-practice/sbirt
• National SBIRT ATTC http://sbirt.ireta.org/sbirt • National ATTC Network www.attcnetwork.org • Online course for docs - http://www.sbirttraining.com/ • Websites http://www.oasas.ny.gov/AdMed/sbirt/index.cfm
http://www.improvinghealthcolorado.org/
http://www.sbirtoregon.org/
http://medicine.yale.edu/sbirt/index.aspx
http://www.bu.edu/bniart/sbirt-experience/sbirt-programs/
http://www.attcelearn.org/
http://www.motivationalinterview.org/
Integrating Adolescent SBIRT in Social Work and Nursing School Education
• Conrad N. Hilton Adolescent SBIRT Grant – Launched October 2014 (3 year effort)
• Overall Aim: To collaborate with schools of social work and nursing and leading professional associations to develop and test an interactive patient/client simulation training program, and to infuse adolescent SBIRT education into existing social work and nursing curriculum.
• Collaborators: CSWE, CCSW, AACN, Kognito, and many others.• Learning Collaborative: Open to Schools of Social Work and Nursing launched
January 2015 (Join Now!)• Visit our Website: http://sbirt.webs.com• For More Info or to Join: Email Danielle Noriega at: [email protected]
Conversations are Powerful Tools to Change Attitudes and
Behaviors
Conversations are a social act of collaboration
Conversations are NOT:- Instruction-giving
- Information delivery- Speeches
- Talk that elicits no meaning
Conversations are an Integral Part of Changing Health Behaviors
Individual/Environment:Medical conditionMindsetConcernsBarriers to changeIntrinsic motivation to change
Behavior
EnvironmentIndividual
Virtual Humans
“Virtual Humans are automated agents that converse, understand, reason and exhibit emotions. They possess a three-dimensional body and perform tasks through dialogs with humans.”
Source: chatterbots.org
Benefits of Virtual Humans
Instructional Benefits: Safe to self-disclose, experiment Increase in engagement, openness Decrease in transference reactions Decrease in social evaluative threat The challenge of the uncanny valley
Other benefits: Personalization of experience Reduce costs of updates “Choose your Avatar” option
Level 1: Voice/Text BasedNextIT - SGT Star, AlmeNuance - NinaApple Siri
Level 2: Animated + VoiceUSC – SimCoachUFL – Pediatrics & Low English Proficiency
Be interviewed by the virtual human to identify their own barriers to change and
build motivation
Learn how to manage health conversations with others
Level 3: Emotionally Responsive 3-D, fully animated Real-life behaviors - Individual personalities - Memory - Emotionally responsive Adapt to players’ decisions
Demo
A 1-hour CNE & CME online simulation; structured as 10-15 min modules
Antoine, 38
Chief Complaint: Back pain, seeking prescription renewal for pain medication
Underlying Issue: PTSD
Judith, 65
Chief Complaint: Arthritis
Underlying Issue: Depression following retirement and loss of daughter on 9/11
Goals: Determine risk of mental health disorder
Collaboratively develop treatment plan that integrates behavioral health
Build motivation to treatment adherence
Goals: Discuss results of PHQ-9
Collaboratively develop treatment plan that integrates behavioral health
Build motivation to treatment adherence
Level 1: Level 2:
Virtual Patients
Emotional Self-RegulationEmotional RegulationReappraisal Strategy
Empathy…
Cognition
EmotionCommunicationMotivational Interviewing
Collaboration, TrustEmpathic ListeningPacing Discussion
…
Mentalizing Empathic Accuracy
… Skills + attitudes + confidence + motivation + knowledge to apply and
engage in real life conversations to drive behavior change
Targeted Skills
Participants: 19% physicians, 55% nurses, 8% Nurse Practitioners, 14% Medical Students, 7% Nursing Students, 26% male, 82% Caucasian, 12% Hispanic, 13% African American. 58% in NYC, 31% North Dakota, 11% in Arizona, Oklahoma, Virginia.
Study Design: Participants completed pre-training, post-training, and a 3-month follow up surveys. Surveys asked a range of Likert scale and open-ended questions to determine changes in skills, attitudes, and behavioral intent.
Results: Primary Care SettingLongitudinal Study with 516 Health Professionals in 6 States (N=87 matched pairs)Goal of Simulation: Increase screening for depression and substance abuse within primary care settings, integration of behavioral health, and treatment adherence by such patients
Method: Empowering physicians and nurses with the skills and motivation to engage in challenging screening and brief intervention conversations with patients that exhibit signs of depression and substance use disorders.
2015. Kognito. All Rights Reserved. Do Not Share without Kognito Approval
Results: Primary Care Setting
• 94% reported that the simulation was well constructed and easy to use• 79% reported that it was relevant to their patient population to a “great extent”
or “very great extent”• 84% reported that the simulated conversations with virtual humans were helpful
to a “great extent” or “very great extent” in learning effective conversation tactics to increase patient engagement, trust, and adherence to treatment plans
• 81% reported that the simulated conversations with virtual humans were, to a “great extent” or “very great extent,” realistic representations of conversations they have with their patients
Quality of Learning Experience
Overall Satisfaction• 84% said the simulation was at their skill level (16% said it was above their skill level)• 95% reported that they will recommend it to their colleagues
Study found statistically significant (p<.05) and sustainable increase at follow-up in learners’ knowledge and skill to:
Results: Primary Care SettingChanges in knowledge and Skill
Behavior ChangeAt 3-month follow-up, as a result of taking the simulation:
• Identify risk factors and warning signs of mental health disorders• Screen patients for symptoms of a mental health disorder• Discuss treatment options• Engage in collaborative decision making about treatment plans• Build intrinsic motivation in patients to adhere to the suggested treatment
plans
• 62% reported increases in the number of patients they screened• 57% reported increases in discussions with patients about treatment options• 52% reported that they engaged more frequently in collaborative decision-making about treatment plans
Questions & Answers
Dr. Tracy McPhersonSenior Research ScientistPublic Health DepartmentNORC at the University of Chicago
Ron GoldmanCo-Founder & CEOKognito
Dr. Eric GoplerudSVP and Director Public Health DepartmentNORC at the University of Chicago
[email protected] Demos: www.kognito.com
Extra Slides
Approach: Immersive Learning Conversations
`
Science Driven and Research Proven Neuroscience Social Cognition Adult Learning Theory
Virtual Humans with Real-Life Behaviors Individual personalities Memory Emotionally Responsive
Kognito’s Virtual Humans - Process
Behavior/Emotion Library3-D Modeling
Embedded in 3-D EnvironmentVirtual Human Controller
Kognito’s Virtual Humans - Process
