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. 

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