The best time to plant a tree...

December 18, 2013

Kim Johnson, MSEd, MBA
Deputy Director, NIATx
Co-Director, ATTC Network Coordinating Office

“May you live in interesting times” has been described as a Chinese curse, but when I looked it up, I discovered it was really originated in America. So much for my awesome introduction about the curse of interesting times.
We are living in interesting times when it comes to health care delivery in the U.S. Whether it’s a curse or a blessing depends on your perspective, so maybe I can pull in another Chinese concept: yin/yang. Or maybe I should just stick with the American version of a silver lining to every cloud. Interesting times are when innovators thrive and when people who have even a little bit of vision and energy can turn a new idea into a successful business venture. Just look at the iPod. A failing business creates a new device and suddenly it becomes not a failing business but an industry leader. Another new device later, and it has a market value bigger than any other company in the country. Ah, only in America!
Apple might have quietly sunk into oblivion. With a market share of 3-4% before the iPod came out, it was pretty much irrelevant that they made great computers. So Apple innovated and came up with a solution to a problem no one recognized they had. Instead of sitting around wondering why no one bought their great product, they created a new product that not only built an amazing new business, but also wound up creating a new market of buyers for their old product. The interesting times that they were living in (the ability to pack tons of memory into a tiny device, cloud computing that allowed for the creating of itunes) provided an opportunity that only they took advantage of.

You know where I’m going with this, right?  The old funding mechanisms for treatment are going away. They aren’t gone yet, but the new funding mechanisms are in place now and the most innovative people in our field are already starting to exploit them. Time is running out for the rest of us to come up with our version of the iPod that maybe will become the only thing that we sell, but may also be the thing that drives people to buy the great services we produce now. Because let’s face it. Even if you have a waiting list, it’s not like people are lined up at your door to pay for what you have to offer. Sometimes you can give it away, but even when it’s free, a lot of people say, “No thanks.”

How do you become innovative? You need to take some time to focus. Sometimes you wake up from a dream and say “Eureka!”but mostly people create new products and services by spending some time looking at market forces, talking to customers, and if you aren’t or haven’t been a customer of the services you offer, imagining what it would be like to be one and what you would want if you were that customer. What would the magic pill do, and is there a way to do that without the magic pill?
So, here is the commercial part of my blog (we are in America, after all). If you’re reading this, you obviously care about treatment improvement. Improving treatment includes improving the business as well as the clinical operations of your agency. It means designing new ways to improve care via new services, new delivery models, and new partnerships. A SAMHSA-funded training opportunity provides the structure and resources that allow you to achieve this, while doing some serious thinking about the future of your organization. It’s called BH Business: Mastering Essential Business Operations. All you need to bring to it is your time and energy, everything else is provided for you.

To quote another probably fake Chinese proverb: “The best time to plant a tree was twenty years ago.” The second best is now.

Kimberly Johnson served for seven years as the director of the Office of Substance Abuse in Maine. She has also served as an executive director for a treatment agency, managed intervention and prevention programs, and has worked as a child and family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a national initiative to increase access to and retention in treatment. She is currently involved in projects with the ATTC Network and NIATx that focus on increasing implementation of evidence-based practices, testing mobile health applications, and developing distance learning programs for behavioral health professionals.

Integration: The Great Debate

December 6, 2013 

Kimberly Johnson, MS Ed, MBA
Deputy Director, NIATx
Co-Director, ATTC Network Coordinating Office


If there's one thing that we seem to be constantly fussing about in addiction treatment, it’s integration.

When I first started in the field, we were still resisting the integration of alcohol and drug abuse treatment. Younger people may be saying “What? That seems silly!”  But it was a big debate at the time. The drug treatment people felt they would be taken over by the bigger, more established alcohol treatment system, and the alcohol treatment system wasn’t sure it wanted to deal with the drug problem.

When I was a student, we kicked people out of treatment for having co-occurring disorders. I think the rationale was that these clients were too sick to focus on their addiction, or something like that. I know I never graduated a single client during my internship because I kept learning they had mental health problems. Toward the end, I started wishing they would be less open with me.

So, when I became the executive director of a treatment agency in the mid-1990s, I was very enthusiastic about trying to figure out how to integrate mental health and substance abuse services for people with co-occurring disorders. It was a big debate because the addiction treatment people were worried about being taken over by the big mental health centers, and the mental health people weren’t sure they wanted to deal with addicts.

Remember what I said earlier about integrating alcohol treatment with other drug treatment?

It was déjà vu all over again.

Now, we’re talking about integrating behavioral health (even though we are still fighting about that term) into primary care. It’s a big debate because the behavioral health providers are worried about being taken over by the big primary care systems, and the primary care systems don’t really want to deal with people with behavioral health disorders.
Maybe I’m just getting old…but I think there’s a pattern here.
What’s funny (or sad, depending on your perspective) is that in many ways alcohol and drug treatment really do remain separate; psychiatric disorders other than substance use disorders are still treated really differently; and very few of us understand the interaction between mind and body at even an elementary level.

But we have to keep trying. And I suppose we have to keep debating, not about whether to do it, but about the best way to do it. We have to debate, we have to experiment, and we have to keep trying to figure out the best ways to integrate, because we still don’t really know.

During the next year, The Bridge, the ATTC Network's quarterly e-journal, will be devoted to the topic of integration in healthcare. The discussion starts with the next issue. If you haven’t yet subscribed to The Bridge, please do. We will review the literature, debate what it tells us, and propose next steps based on where our research and discussion leads us. Join us in this debate. It will be fun.
I’m trying to imagine what the next big integration debate will be. I’m too blinded by the current controversy to think too far ahead, but maybe you have some ideas.

The SAMHSA-HRSA Center for Integrated Health Solutions  (CIHS) offers a wealth of resources and information dedicated to healthcare integration. (And the images in this post are from the CIHS website--check out their excellent infographic on the benefits of integrated care.)

Kimberly Johnson served for seven years as the director of the Office of Substance Abuse in Maine. She has also served as an executive director for a treatment agency, managed intervention and prevention programs, and has worked as a child and family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a national initiative to increase access to and retention in treatment. She is currently involved in projects with the ATTC Network and NIATx that focus on increasing implementation of evidence-based practices, testing mobile health applications, and developing distance learning programs for behavioral health professionals.

Mobile Health: A Brave New World

November 26, 2013

 Andrew Isham and Dr. Bret Shaw, mobile health researchers at the Center for Health Enhancement Systems Studies (CHESS) and NIATx, have co-authored a chapter in a new book, Health Communication: Strategies for Developing Global Health Programs.

The chapter, titled “Developing and Testing Mobile Health Applications to Affect Behavior Change: Lessons from the Field,” focuses on how to design mobile (mHealth) applications that can be potentially powerful tools for behavior change. The authors are also part of the team that has developed A-CHESS, the mobile phone-based relapse-prevention system that offers support to alcohol and drug dependent people when and wherever it is needed.
In the Q&A that follows, Isham shares his experiences related to this rapidly expanding field of research.

Q: Who is the intended audience for Health Communication: Strategies for Developing Global Health programs?

A: The book is written for researchers and clinicians, but is really for anyone involved in or interested in the field of health communications. Health communication technology is exploding right now, and there’s a lot of hype, both positive and negative, about its possible impact on behavioral health. Some think that mHealth is the answer to many issues in behavioral health, from the treatment gap to treatment modalities. Others perceive mHealth as a passing fad, or worse, a threat to quality treatment. This book offers a balanced view that I think puts a check on the hype and addresses the concerns of those who are not entirely convinced of the potential benefits of mHealth.

Q: The chapter that you wrote with Dr. Shaw covers mobile health or "mHealth" applications. What is the definition of an  mHealth application? 

A:  Right now, most mHealth applications are software programs delivered through a mobile device such as a smartphone. These applications are being developed at an amazing rate, and the app stores (Apple’s iOS App Store, Google Play Store, the Amazon Appstore) offer thousands for people to purchase. These apps help people manage health issues ranging from diabetes and obesity to smoking cessation and medication adherence. 
While smartphones are currently offering the majority of mHealth applications, other devices on the market now or expected to be in the near future include wearable devices such as fitness trackers, smartwatches, and GoogleGlass. It won’t be long before we see a proliferation of other less conspicuous mHealth applications such as clothing that monitors vital signs, or algorithms for early diagnosis of mental health disorders using data that is already in the cloud.

Q: What are some of the benefits that mHealth offers the field of behavioral health?

A: The ability to unobtrusively capture lots of data that may be used to create individual behavioral models that predict key behavioral moments and provide custom intervention in real time. In this way, mHealth can help diagnosis and intervention to move from the clinic to the patient’s “in vivo” environment. In the current model, people receive treatment primarily in a clinic setting—but they recover out in the community. Mobile health gives people access to their treatment at all times. In a sense, they can carry their treatment with them. Or better yet, their treatment is with them at all times without them having to think about it. For example, A-CHESS, the application that I’m working on as part of the study team at CHESS (the Center for Health Enhancement Systems Studies at the UW-Madison) has a feature that allows a patient who is struggling with a trigger to access a peer support network or a counselor at any time. This aspect of mHealth can give clinicians more information—or perhaps more useful information—in a more timely fashion about what’s working and what’s not working in a patient’s treatment plan. It changes the definition of “in treatment” and allows clinicians to make adjustments tailored to the patient’s needs more quickly.

The data available from mHealth applications also allows for proactive rather than reactive treatment. A-CHESS, for example, has a weekly check-in feature that people use to make an inventory of their thoughts, feelings, and potential triggers, and how they react to them. In our first study of A-CHESS, this was a tool clinicians could use to react to a patient’s relapse. Now, it’s become a tool that alerts both the patient and the clinician to a possible relapse, and can prevent it: either A-CHESS will offer the patient a strategy for preventing relapse, something that’s proven effective for that patient in the past, or A-CHESS will engage a counselor to intervene. Mobile health also has the ability to promote integration of behavioral healthcare with primary care, or a movement from silo-ed to integrated care. We know that many people with substance use disorders also suffer medical problems related to their substance use—but care for the multiple issues is not connected. mHealth data may eventually lead to a deeper understanding of how behavioral health and primary care issues are interrelated, as well as provide opportunities to intervene in a manner that honors this systemic nature.

Q: What do you consider to be some of the drawbacks of mHealth applications?

A:  One of its great advantages—the access to timely data—also presents greater potential for abuse by payers, employers, and anyone who has a financial stake in healthcare.

All the hype surrounding mHealth right now presents a drawback, as it’s creating a polarization between those with opposing views about its benefits. Some techies consider mHealth an inevitable panacea, and some traditional practitioners consider it a threat to what really works. I think both are misguided. This polarization could slow down adoption of really useful applications.

Privacy is a big concern that is being addressed at research institutions that are developing mHealth apps, as well as government agencies such as the FDA. Again, all that data could be abused.

Another issue is quality. There are a lot of ways for an mHealth application to fail. A good idea could be crippled by a sloppy user interface. A well-designed and useful application might become obsolete if it’s not updated to keep up with improving operating systems. And no mHealth application is going to have long term effect unless the users (patients or clinicians) believe in it and are not burdened using it. Consumers and clinicians will need assistance in selecting quality applications that cover all the bases.

Q: In addition to the book, what are some other resources available now that people can turn to for more information on mHealth? 

In the ATTC Network, the National Frontier and Rural ATTC is doing a lot of work on telehealth to improve access to treatment.

To keep up with the latest in mHealth, check out mHealth News ( For a thought-provoking and balanced take on the future of mobile technologies, read Jaron Lanier’s books, You are Not a Gadget  and Who Owns the Future?

Andrew Isham, M.S., is a researcher at the Center for Health Enhancement Systems Studies, University of Wisconsin - Madison. Isham has a BS in mechanical engineering, a minor in psychology, and an M.S. in industrial engineering, with a specialization in health systems engineering. Isham is the director of development for the randomized clinical trial for Addiction-CHESS (A-CHESS), a smartphone application designed to help patients leaving inpatient addiction treatment avoid relapse. 

What happens if they say "Yes"?

November 21, 2013

Catherine Ulrich Milliken, M.S.W., LICSW, MLADC, LCS 
Program Director,The Dartmouth Hitchcock Medical Center Addiction Treatment Program 
Instructor, Psychiatry 
Geisel School of Medicine at Dartmouth.

In my last blog post, “Start with the Why,” I wrote about how the Addiction Treatment Program at Dartmouth Hitchcock Medical Center is using the NIATx process to implement SBIRT across settings—in our case, in the Medical Center’s OB-GYN clinics.

Since then, our change team has made some exciting discoveries, and I attended the SBIRT Training of Trainers (or TOT-October 14–16, Kansas City) offered by the National Screening Brief Intervention and Referral to Treatment ATTC. Many thanks to Laurie Krom, director of the ATTC for sponsoring me, and to the fabulous trainers, Holly Hagle and Jim Aiello of the National SBIRT ATTC.

The overall goal for the training was to help trainers develop the knowledge, skills and abilities needed to effectively train others on the various tasks involved in providing SBIRT services. We learned about the conceptual framework of SBIRT as a public health model and its impact as a system change initiative. We reviewed and practiced the skills necessary to provide, and train others to provide, screenings, brief interventions, and extended brief interventions. We also discussed the business of SBIRT including information on reimbursement for services. Thanks to the training, I feel ready for the challenge of training my team members and others on SBIRT—but more about that later.

Our change team tackled our first barrier with a month-long PDSA Cycle in October focused on the question: How do we ask? Specifically, how do we ask pregnant women about their alcohol and substance abuse use?

Concerns had been raised about pre-screening women for substance use with their families and partners present. The change team suggested a change in practice that some thought would be impossible: separating the patient from family members to conduct the pre-screen about substance use and to ask questions about domestic violence. The team anticipated push back from the patients and their families and had concerns about offending them. What we discovered, much to our surprise, was that no one was offended or refused.

With this success, it was clear that the change team was gaining confidence and ready to move forward with creating a workflow diagram to map the flow of SBIRT in the clinics. They were also eager to learn how to administer the screening tools and conduct brief interventions, so the timing of the SBIRT Training of Trainers could not have been better.

The team recognized several areas of need regarding training. They identified the need to provide a department-wide training on the SBIRT initiative and the change team’s progress to date. They also expressed concerns regarding training on administering screening tools, conducting brief interventions and treatment and an overall refresher on current drugs of abuse.

After we reached consensus on our SBIRT Process Map for clinic flow, we agreed to explore dates for a grand rounds training on SBIRT and the change team’s progress. We also selected dates for me to conduct an implementation training for the change team to allay their fears about “What happens if they say yes!” As a trainer, my challenge will be to condense a two-day training into an hour long grand round presentation and a series of 1.5-hour provider trainings. Having attended the TOT, I feel ready for the challenge and confident that I have the resources and the network I need to move forward.

The Specialty Clinic for Pregnant Women (the “T” in our SBIRT adventure) that I wrote about in my previous blog post is getting a lot of attention, and we are working to enhance the program by partnering with various experts in the field of pediatrics and early intervention. Bonny Whalen, MD (medical director of the Newborn Nursery at Dartmouth-Hitchcock Medical Center assistant professor, Department of Pediatrics, Geisel School of Medicine at Dartmouth) came and spoke to our clinicians and our patients about Neonatal Abstinence Syndrome (NAS). She was so warm and reassuring, answering all of the questions and concerns raised. Dr. Whalen is working on a pilot program with our women so that they will be able to room in with their babies if they need treatment for NAS.

What has become clear to us is that this partnership of integrated care is benefiting all involved. As we continue to share our experience, new champions come forward, and our vision becomes clearer and more comprehensive, despite the perceived barriers. Our change team invites you along for our next challenge: training and implementing SBI. We welcome your feedback, experience and wisdom!

We hope you find this blog helpful as you consider implementing SBIRT across settings. Below are some useful resources on SBIRT and SBIRT Trainings:

Catherine Ulrich Milliken, M.S.W., LICSW, MLADC, LCS, is the Program Director for The Dartmouth Hitchcock Medical Center Addiction Treatment Program and an instructor in Psychiatry at the Geisel School of Medicine at Dartmouth. Previous academic appointments included University of Southern Maine, University of New England, and University of New Hampshire. She has worked passionately to improve the care and treatment of women's mental health and substance issues for the last 15 years. Before working at Dartmouth, she was the Director of Outpatient Services at Crossroads for Women, which provides gender‐specific and trauma‐informed outpatient programs and services for substance abuse and mental health, as well as residential rehabilitation and halfway house services for substance abuse in Portland, Maine. During that time, she also saw clients in private practice, specializing in adult psychotherapy, substance use and women's issues and worked with clients struggling with HIV and AIDS diagnoses. She conducts training on the basics of chemical addiction, tools for leading groups, exploring the relationship between substance abuse and child maltreatment, and women's treatment concerns, among other areas. 

Happy Birthday, ATTC Network!

November 15, 2013

Maureen Fitzgerald
Communications Coordinator, ATTC Network
Editor, NIATx

2013 is a big year for the ATTC Network: this year, the Network celebrates 20 years of helping the addiction treatment and recovery services field adopt and implement evidence-based practices. Over the past two decades, the Network has worked to build the knowledge and skills of the workforce that addresses the needs of people with substance use or other behavioral health disorders.

The continuing support from SAMHSA’s Center for Substance Abuse Treatment has allowed the Network to evolve and grow into a vital resource for the field, bringing researchers and clinicians together to address the ongoing need for effective treatment. Thousands of clinicians have been trained in evidence-based practices. And because of the work of the ATTCs, the concept of technology transfer as a process that extends from research design through implementation in treatment programs has become standard knowledge.

How much do you know about the ATTC Network and all that it has accomplished in the past two decades? Test your knowledge with the 20 Questions Challenge!  Be the first to answer all the questions and you’ll win an ATTC messenger bag filled with 20 ATTC products and other goodies. 

(Hint: You can find answers to all 20 questions on the ATTC website.)

The ATTC 20 Questions About 20 Years Challenge

1.   In what year was the ATTC Network founded?  (Yes, that’s a giveaway….)
2.   How many states does the ATTC Network cover today?
3.   What are the ATTC Network’s priority areas?
4.   When did the ATTC publish The Change Book: A Blueprint for Technology Transfer?
5.   When did the NIDA/SAMSHA Blending Initiative begin?
6.   The ATTC Network also covers the Pacific Jurisdictions. What locations do they include?
7.    Where is the first international ATTC and in what year was it created?
8.    When did the Network complete the national workforce study, Vital Signs?
9.    How many Regional Centers comprise the ATTC Network in 2013?
10. What are the names of the National Focus Area ATTCs?
11.  Where are the offices of the Network Coordinating Office located?
12. When did the ATTC and NIATx launch the Service Improvement Blog?
13.  What is the name of the Network’s monthly electronic newsletter?
14.  How many courses does the ATTC eLearn currently offer?
15.  Which monthly webinar series hosted by the Network offers the opportunity to earn continuing education credits?
16. How many video views are there on the ATTC YouTube account?
17. Which ATTC Network website resource serves as a term and definition resource for the field?
18. What is the name of the ATTC Twitter account? (Hint: @......)
19. Which ATTC electronic publication features views on technology transfer from leading researchers?
20. Which ATTC web resource provides information on institutions that offer degrees in addiction studies?

Submit your answers to: by 5pm on Tuesday, December 31,  2013. We’ll announce the winner and provide the answers in an upcoming blot post. Good luck!

Making the case for MAT

October 28, 2013

Michael Boyle, Associate Researcher
Center for Health Enhancement Systems Studies

Despite their proven effectiveness, medications for substance use disorders are still not widely prescribed. Results of the National Treatment Center Study conducted in 2009–2010 revealed that 62% of publicly-funded providers did not offer a single medication for the treatment of a SUD. I don’t think much has changed since the study was published. I’d like to offer a few factors for treatment organizations to weigh when considering whether or not to offer medications for substance use illnesses (a term that I prefer, as opposed to substance use “disorders.”)

The National Quality Forum (NQF) is a public-private partnership that develops consensus measures for a variety of health conditions. In 2007, the NQF released 11 standards for treating substance use illnesses. Four of the standards highlight the importance of using medications as a component of treatment for detoxification, opiates, alcohol, and nicotine. The standards are titled “voluntary,” but the aim is to encourage payers to establish contracts and provide reimbursements only to organizations that implement them.

Treatment organizations can meet the NQF standards for medication-assisted recovery (with the exception of using medications for detoxification) by referring to providers who can prescribe. For organizations that lack resources to employ medical staff who can prescribe medications, developing a relationship with a local Federally Qualified Health Center may be a viable option, particularly in states that are expanding Medicaid coverage. Another benefit of linking with an FQHC is that people in treatment for a substance use illness can also receive primary care.

And failure to offer FDA-approved medications for a substance use illness may result in lawsuits for malpractice.

That’s one idea that came up a recent TweetChat (#attcbridge) on the Fall 2013 issue of The Bridge, an electronic journal published by the ATTC. This issue of The Bridge focused on the consumer’s and family role in expanding medication-assisted treatment (MAT). I joined my fellow contributing editors and others to share our thoughts on this topic, in 140 characters or less on the TweetChat.

(You can follow the TweetChat conversation on the ATTC Network homepage.)

Tweeting about the legal implications of not offering approved medications for substance use disorders brought up parallels to primary care. A doctor who diagnoses hypertension but doesn’t tell the patient about effective medications—or offer a prescription—is asking for legal trouble if the patient later suffers a stroke. The medical record leaves a trail that will most likely result in a lawsuit.

There’s also a business case for offering medication-assisted recovery, using Suboxone in particular. For years, even patients with limited financial resources have been seeking medication at private-pay methadone clinics. These same patients would be willing to pay for medication and the related physician and counseling visits that help them repair relationships, obtain employment and housing, and basically get their lives back. Family members are often willing to help pay for effective treatment for their loved ones. And patients also see a cost benefit, as the medication and related treatment costs are less expensive than opiates.

These are just a few factors that I urge organizations and clinicians to consider when making decisions about using the medications now available to help their patients manage a substance abuse illness.

Share your thoughts with Mike in comments section that follows!

Michael Boyle is an Associate Researcher at the Center for Health Enhancement Systems Studies at the University of Wisconsin–Madison and provides consulting services. He was formerly President and CEO of Fayette Companies, a behavioral health organization located in Peoria, Illinois, and is the Director of the Behavioral Health Recovery Management project. Boyle recently served on a National Quality Forum committee charged with defining an episode of continuing care for a substance abuse treatment encounter. He has authored several articles and book chapters. His current activities include integrating mental health, addiction and primary care services, implementing evidence-based clinical practices within recovery oriented systems of care, and exploring the development and use of electronic technologies to support behavioral health treatment and recovery.


Understanding the Right Customer

October 2013

Jay Ford, Ph.D.

Executives at Procter and Gamble learned some powerful lessons when seeking to expand their customer base to India. Their experiences highlight the importance of two  NIATx principles: understanding the customer and getting ideas from outside the field. The P&G story highlights the importance of understanding the right customer.

In 2008, executives at Gillette, which is now a division of Proctor and Gamble, wanted to increase its market share in India among men who shave. The prior introduction of a new shaving product in 2002 initially failed. At that time, they introduced a new razor with a bar to unclog hairs that collect in the razor. Market testing among Indian students at the Massachusetts Institute of Technology indicated that the new product was a big improvement. However, the introduction into the market was a complete failure. Why? The answer was simple:  the lack of running water.  Most men in India shave with a cup of water, which rendered the new razor useless. Alberto Carvalho, Vice-President of Global Gillette called it an “Another ‘aha’ moment’." Simply stated, they had not taken the time to understand the needs of the right customer.

So in 2008, Gillette was ready. They sent 20 staff to India. Once there, they conducted “walk-throughs” with their customers, spending over 3,000 hours watching men shave under many different circumstances and situations. They also conducted focus groups, another powerful tool to help understand the customer. Armed with this knowledge, they were able to develop and introduce new products in the market. Efforts to understand the needs of the right customer have resulted in an 11.8% increase in market share. To learn more about Gillette’s story, I encourage you to read the recently published article about their experience.

The implementation of the Affordable Care Act will change the market place for behavioral healthcare organizations. Through Health Information Exchanges, many more people with new  access to behavioral health care will will be seeking services. These people will become your new customers. The Gillette story highlights the importance of understanding their needs. 

Applying the first NIATx principle: Understand and Involve the Customer takes on a new meaning now. A walk-through conducted now should focus on understanding the needs of the right customer. Several California providers recently told me about how the new Health Information Exchanges present opportunities for them to provide care for different populations. As a result, they are taking steps to understand customer needs to show them--as well as new payers--that their services result in quality outcomes.

The choice is yours. You can repeat Gillette’s failed experience of 2002 or you can follow the approach they took in 2008 to clearly understand the needs of the right customer. What approach will you chose? 

What new customers will your organization be serving in the near future?  How will you know that you're  providing quality services for the right customers? Share your thoughts with the ATTC/NIATx Service Improvement Blog!

Assistant Scientist
Center for Health Enhancement Systems Studies/NIATx 
University of Wisconsin-Madison

Inspiring Change through SBIRT: Start with the “Why”

October 2, 2013

Catherine Ulrich Milliken
Director, Addiction Treatment Program
Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

I recently saw a fantastic  Ted Talk by Simon Sinek on how great leaders inspire action.   I was struck by the notion that people don’t buy what you do, they buy why you do it. What is your cause?  Your purpose and belief? How are they reflected in what you do?
As The Dartmouth Hitchcock Medical Center Addiction Treatment Program (DHMC-ATP) staff began to work on strategic planning for the next year, we recognized the need to clarify our “why.” In doing so, we realized that we must do more to address the entire SPECTRUM of substance use from a preventative, health promotion orientation.
Like treatment providers across the country, DHMC ATP has seen in increase in the number of pregnant women in need of substance abuse treatment. According to SAMHSA (2012), 5 percent of pregnant women are current illicit Drug Users. Between 2000 and 2009, maternal opioid use at time of delivery increased more than four-fold, with a 35% increase in healthcare expenditures for neonatal abstinence syndrome (Patrick et al., 2012). The incidence of opioid-related neonatal abstinence syndrome has increased nearly three fold (Chopra et al., 2009). These facts combined demonstrate that opioid use during pregnancy is a growing problem of great public health significance—and one that the staff at the medical clinics and hospital our center is affiliated with is facing.
Our program identified the need to integrate SUD treatment providers into settings where we can affect change with those who may be at risk for developing substance use disorders, and at the same time, welcome medical professionals into our setting to provide care for our patients.

The How: Relationship building

As part of a medical center that includes ob-gyn clinics and a hospital, ATP could easily identify partners to work with on meeting this need. Building upon existing provider relationships between the Geisel School of Medicine Department of Psychiatry and DHMC Maternal-Fetal Medicine, we came to a shared “why.” We all believe in healthy moms and healthy babies and strive to provide caring and thoughtful evidence-based, integrated, cost effective care.
Together, we agreed to implement SBIRT into the OB/GYN clinics at Dartmouth Hitchcock Medical Center. ATP staff drafted a one-page proposal and convened a meeting with stakeholders from DHMC Maternal Fetal-Medicine to pitch expanding care for pregnant women beyond traditional treatment—to include a specialty clinic for pregnant women at the ATP, as well as screening and brief intervention in the OB/GYN clinics. We also applied for an auxiliary grant to help fund contingency management in the clinic and consultation and training for the SBIRT initiative and are hopeful we will receive funding.
From this shared vision, the DHMC ATP developed a Specialty Clinic for Pregnant Women, which opened in July 2013. The clinic provides individual, group, and medication-assisted substance treatment as well as on-site access to psychiatric care, and soon to include obstetric care, and case management services. As they say, “If you build it, they will come,” and they have! To date we have a group of approximately ten women participating in group, individual and medication-assisted substance abuse treatment. We are averaging two new evaluations per week and will need to plan for expansion in the near future. We have the “T” in SBIRT and by demonstrating our commitment to this shared vision, are working implementing the “SBI” in the DHMC OB/GYN clinics. Women are most excited and looking forward to “one-stop-shopping:” receiving prenatal care and substance abuse treatment in one clinic.

Adding who, what, when and where: Process improvement

The implementation process is no small feat, but could not have gained momentum had we not secured buy-in with a shared “why.” By building upon existing relationships, we identified project champions from each department and formed a change team, following the NIATx process improvement model.
We have decided to use the NIATx rapid-cycle change process with PDSA (Plan, Do, Study, Act) Cycles in our efforts to implement SBIRT. PDSA cycles allow the change team uses quickly test the effectiveness of potential solutions generated from barrier assessment and process mapping  exercises.
One of the first barriers our change team identified wasyou guessed it—reimbursement for SBIRT services. New Hampshire has not yet expanded Medicaid or released the reimbursement codes. Other barriers we identified include workflow and training issues across systems. Our next change team meeting will tackle ways to address these barriers, and decide which one to target in our first change project. We will also choose our screening tools and develop a process map of the workflow.
Then it’s off to Kansas City for the SBIRT Training of Trainers, (October 14-16) offered by the National Screening, Brief Intervention & Referral to Treatment ATTC. From this training, I hope to bring home tools to address training issues and help the team move forward with planning our first PDSA Cycle of SBIRT.
As we continue on our journey of implementing SBIRT into the OB/GYN clinics at the Dartmouth Hitchcock Medical Center, our change team invites you along for the ride and welcomes your feedback, experience, and wisdom!  Look for an update on our progress in a future blog post.
We hope you find this blog helpful as you consider implementing SBIRT across settings. Below are some other useful resources on SBIRT:
Catherine Ulrich Milliken, M.S.W., LICSW, MLADC, LCS, is the Program Director for The Dartmouth Hitchcock Medical Center Addiction Treatment Program and an instructor in Psychiatry at the Geisel School of Medicine at Dartmouth. Previous academic appointments included University of Southern Maine, University of New England, and University of New Hampshire. She has worked passionately to improve the care and treatment of women's mental health and substance issues for the last 15 years. Before working at Dartmouth, she was the Director of Outpatient Services at Crossroads for Women, which provides gender‐specific and trauma‐informed outpatient programs and services for substance abuse and mental health, as well as residential rehabilitation and halfway house services for substance abuse in Portland, Maine. During that time, she also saw clients in private practice, specializing in adult psychotherapy, substance use and women's issues and worked with clients struggling with HIV and AIDS diagnoses. She conducts training on the basics of chemical addiction, tools for leading groups, exploring the relationship between substance abuse and child maltreatment, and women's treatment concerns, among other areas.  

Do you have questions or comments for Catherine?  Post them here, or e-mail Catherine at:


 SAMHSA, 2012

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