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

Patrick SW, Schumacher RE, Benneyworth BD, et al. “Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009," JAMA. 2012 May 9;307(18):1934-40. doi: 10.1001/jama.2012.3951. Epub 2012 Apr 30.

 Chopra, M.P., et al., “Buprenorphine medication versus voucher contingencies in promoting abstinence from opioids and cocaine.” Exp Clin Psychopharmacol, 2009. 17(4): p. 226-36.

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