October 2, 2013
Catherine Ulrich Milliken
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 was—you 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:
Do you have questions or comments for Catherine? Post them here, or e-mail Catherine at:
References
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.
No comments:
Post a Comment