Project Description

The Indiana University School of Medicine (IUSM) is integrating SBIRT into Indiana’s health care system to improve the health of the large number of adolescents and adults at risk of substance abuse disorders.

IU School of MedicineOur primary goal is to train physicians to provide SBIRT services and to promote systemic change in residency programs by integrating SBIRT into the curriculum on a long-term basis. We are also developing exportable models of how to integrate SBIRT services into comprehensive outpatient clinic settings by involving allied health professionals and utilizing a variety of instruments using information technology as well as conventional tools.

A key objective is to develop physician buy-in to the importance and potential impact of SBIRT. That is, when they take up practice around the state they will see SBIRT as a priority and support practices by allied health personnel. By incorporating SBIRT into the residency continuity clinics, we are increasing access to interventions for both the residents’ and their attending physicians’ patients and the availability of brief interventions in the clinics. As more primary care physicians are trained in Indianapolis and around the state, additional access to intervention will be achieved. In lower risk areas, SBIRT is likely to have a greater role in prevention of harmful use and underage drinking.

The ultimate goal is to have every resident trained in Indiana in medicine, medicine-pediatrics, pediatrics, family medicine, emergency medicine and OB-GYN to provide SBIRT as part of their practice.

Who We Are

Dr. David Crabb will have oversight of the entire program. Dr. Crabb’s effort for this project is supported by the Indiana Alcohol Research Center Translational, Education, and Outreach component.  He will serve as the representative of the project to the external stakeholders (other residencies, other sites in the state, and with the Wishard leadership in his role on the board of Trustees).

Dr. Julie Vannerson are general internists who were recruited as clinician-educators and who practice in the Wishard PCC.  They will participate in the development of the curriculum, the creation of the training workshops and their supervision, be responsible for coordination of the patient teaching panels in the clinic, the one-on-one training of the residents in concert with the motivational trainers and counselor.  They will serve as the liaison for the evaluation section, and the dissemination of the project to other residencies and sites in the latter years.  Two physicians will share this role to ensure that one of them is usually available for the training and oversight of the clinic.

Drs. Finnell, Grannis, Aalsma, and Abernathy are members of the departments of emergency medicine, family medicine, pediatrics, and obstetrics and gynecology, respectively.  They will serve as the clinician trainers for their residents in their continuity clinics or other practice venues (e.g., the emergency department).  Their involvement is phased in between years 2 and 4.  Their effort is less than that of Leary and Vannerson because their residency programs are smaller that of the internal medicine residencies, and a fair amount of the curriculum and implementation development will be adapted from the work done by Leary and Vannerson.

Dr. Richard Goldsworthy is Director of Research and Development at the Academic Edge, Inc., a learning and media research company located in Bloomington, Indiana.  Dr. Goldsworthy has served as principle investigator on more than 25 federal grants and contracts ranging from interactive STD prevention curricula for middle school age learners, to ADHD and FASD informational modules for lay persons, to web-based medical training on SBIRT, STI prevention, and other social and interpersonal professional skills.  Dr. Goldsworthy is serving as the educational and technological design consultant for the effort.

Partnering Institutions

Academic Edge: Academic Edge (Richard Goldsworthy, Ph.D. CEO/Director, Research & Development) is assisting in the design and production of the IUSBIRT.ORG portal and the associated web-based training modules for SBIRT@IUSM.  The company has produced engaging media for both the private and public sector.  Current projects include a multimedia HIV/STD curriculum for middle schools, the application of streaming video and web-based conferencing tools to enhance children’s conflict resolution skills, VHS and DVD training modules on HIV/STD risk assessment and counseling, and the development of a web-enhanced CD-ROM on Fetal Alcohol Syndrome/Fetal Alcohol Effect for care providers.

Indiana Prevention Resource Center: The IPRC is experienced in administering before and after questionnaires to training participants in the medical residency programs to evaluate processes and outcomes.  Dr. Ruth Gassman has done NIAAA-funded research on predictors of SBIRT implementation and related work with the University of Connecticut Health Center produced scales that measure training competencies among physicians with a variety of medical specializations.  The competencies measured include objective knowledge, perceived barriers both at the individual and organization level, attitudes, and self-efficacy in implementing SBIRT in the clinical setting.  The questionnaires will include items measuring acquisition and retention of outcomes, such as understanding of the association of medical conditions with substance abuse, screening tools, brief intervention procedures and evidence of their effectiveness, detoxification procedure, prescribing of effective medications, ongoing medical management, etc.  Use of the unique identifiers will allow for longitudinal analyses of data to respond to questions such as where training may be improved, on what content booster training would be beneficial, and what subgroups training is most effective for and why.  She will travel to Indianapolis from Bloomington weekly for the first 4 months, then monthly thereafter.

Indiana University Medical Group – Primary Care Clinic: The SBIRT program is being piloted in the IUMG PCC.  Dr. Vannerson is a general internist who was recruited as clinician-educator and who practices in the Wishard PCC.  She has dedicated herself to medical education: has participated in the teaching retreats held for residents, as well as evening educational improvement sessions.  Dr. Vannerson will participate in the development of the curriculum, the creation of the training workshops and their supervision, coordination of the patient teaching panels in the clinic, and coordination of one-on-one training of the residents in concert with the motivational interviewing trainer and SBIRT counselor.  She will serve as the liaison for the evaluation section, and the dissemination of the project to other residencies and sites in the latter years.  In years 2 and 3 we will include support for physician leadership for additional residencies: Drs. Finnell (Emergency Medicine), and Grannis (Family Medicine).  In years 3 and 4 we will add support for Dr. Abernethy (OB-GYN) and Aalsma (Pediatrics) as their residents begin to participate in the program.  In effect, this is a “train the trainer” model which will disseminate this expertise to 5 different residency programs.

Midtown Community Mental Health Center: The SBIRT Program Coordinator, Joe Bartholomew, MSW, LCAC, CHES, will have the role of operational management of the overall project, including coordination of the interactions of the motivational trainers with the residents, the counselor, the creation of the curriculum, meetings, and the collection of data for evaluation.  This position is essential for managing a program as large as ours (approximately 150 internal medicine and medicine-pediatrics residents alone, with up to 300 residents per year by the end of the grant).

Substane Abuse Counselor, Lisa Session, BSW,  will provide onsite expertise in the screening, assessment of substance abuse problems, and immediate availability of referral level care beyond that provided by brief intervention.  This individual will spend most of her time situated in the PCC to allow immediate access to referral.  Provision of this service is justified by our previous experience in the Bellflower clinic where SBIRT was piloted several years ago: there was a high rate of referred individuals simply not following up with a later appointment.

Motivational Interviewing trainer, Meg Kovacs, MSW, LCSW; will take a leading role in training the residents and allied health personnel in the screening and delivery of brief intervention for substance abuse.  She will be Midtown Mental Health staff  (Midtown Mental Health is an arm of the Health and Hospital Corporation, which oversees the provision of mental health services at Wishard Hospital, free standing Midtown Mental Health clinics, and more recently the community health centers that are run by Wishard Health Services).  This will provide the trainers with extensive networking with Midtown, including the referral and treatment processes that will follow screening and brief intervention in many cases.

Regenstrief Institute: The Regenstrief Institute will work with current programmers and physicians to establish physician messaging specifics and electronic patient record protocols.  Regenstrief and its informatics group is the local leader in the management of electronic medical records in the central Indiana region, and has extensive experience in the use of physician reminders and decision support messages that is built into the day-to-day operations of the Wishard community health clinics.  They will create the SBIRT reminder in the medical record system used by all the residents involved in this training.  They will play a central role in the evaluation process. Regenstrief Institute employs professional research staff who will ensure the GPRA, process, and outcome measures are collected and reported within a strict administration schedule.  They will track SBIRT screening rates performed by each resident in their “scorecard” along with other preventive services so that we can track the effectiveness of the training and give the residents feedback.  In addition to the GPRA data, we will be in an excellent position to analyze true medical and social outcomes of the SBIRT interventions.  This could include analysis of medical and social problems before and after SBIRT, numbers of visits to the ED and hospitalizations, and compliance rates for substance abuse treatment.

What People are Saying

Data recently released by the National Center for Health Statistics show drug overdose deaths increased for the 11th consecutive year in 2010. Pharmaceuticals, especially opioid analgesics, have driven this increase.–Research Letter, JAMA 309(7).

I have applied [SBIRT in] my clinic.

Simple, fast, and effective techniques!

I realised that if the right technique was utilized motivational interviewing was relatively not so time consuming….. Knowing that screening and brief intervention can be done in less then five minutes!

I liked the readiness ruler and the figure of pyramid substance use.

Clear presentation of strategies that help approaching substance abuse through motivation interviewing.

Great tangible communication techniques!

The training was very useful in that it allowed us to learn and practice different techniques in talking with patients and how to interact with them best regarding substance abuse.

Easy to remember questions and easy steps to address drinking habits and resistance to change.

The training helped… establish a pattern for dealing with alcoholism, and other common underlying problems for patients.

Provided an organized method and approach to help change patients’ behavior to improve their health.

The role playing and real playing exercises were actually very helpful in getting me to see how effective this method can be.

Good interactive session with opportunity to practice.

Quick + effective tricks to have effective discussions on sensitive issues without being threatening.

These services can be de delivered at low cost (median cost $4 per screening and $48 per brief intervention, in line with reimbursement by Medicaid and Medicare) to medical systems.

Bray JW, Zarkin GA, Hinde JM, Mills MJ. Costs of alcohol screening and brief intervention in medical settings: a review of the literature J Stud Alcohol Drugs. 2012,73::911-9.

A systematic review found that among those receiving SBIRT interventions, consumption decreased by 3.6 drinks/wk, 12 % fewer subjects reported heavy drinking episodes, and 11% more individuals were drinking at levels below prudent over 12 months compared with controls.

Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, Yeatts J, Swinson Evans T, Wood SD, Harris RP., Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. Report No.: 12-EHC055-EF. AHRQ Comparative Effectiveness Reviews.

As a SBIRT provider and healthcare consumer, I appreciate, and understand what SBIRT is accomplishing. SBIRT (Screening, Brief Intervention and referral to Treatment) is a simple, effective and invaluable screening conduit that allows for real talk between the patient and healthcare provider about Alcohol and Drugs and the potential risk they pose. Patients are subsequently provided information and choices in which to address their individual needs.

Lisa Session, BSW

SBIRT Counselor

Primary Care Center 4

I have been using SBIRT tools frequently in my primary care practice and find them very helpful. I especially use the readiness to quit scale with most of my patients. It gives me an objective measure of their progress in terms of quitting and helps me track their progress. SBIRT training has also greatly helped me in knowing how to approach the subject of substance abuse and the plan to follow to assist the patients in cessation.

Arslan Shaukat, MD

Department of Internal Medicine, PGY-2

Indiana University School of Medicine

After completing the SBIRT training, I began to use the motivational interviewing techniques in my primary care clinic. I found that using the tools I learned in the training I could effectively engage my patients in discussion and simultaneously assess their readiness to change abusive behaviors in a time efficient manner compatible with a routine clinic visit. In addition, once I have had the initial discussion with patients, I can address the issue at a later visit and have objective tools to assess for progress. I have multiple examples of success using these techniques with patients, including cases of alcohol and illicit drug abuse. Overall it’s a useful tool for anyone who may have to deal with substance abuse in their patient population.

Christopher Kniese, MD

Department of Internal Medicine, PGY-2

Indiana University School of Medicine

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