Embracing Change: The Fluidity of Evidence-Based SBIRT

 By Diana Padilla, CLC, CARC, CASAC-T, on behalf of Northeast & Caribbean ATTC 

The SBIRT Framework 

Screening, Brief Intervention and Referral to Treatment, also referred to as SBIRT, is an evidence-based practice designed to intervene with people who are at risk of health and psychosocial consequences stemming from their risky levels of alcohol consumption and/or other substance use.

As a comprehensive, integrated, public health approach, the components of the SBIRT model include screening for substance use, and when warranted, a brief intervention (dialogue using Motivational Interviewing core communication skills) and referral to treatment. An array of non-substance use disorder treatment settings provide opportunities to identify and reduce harmful levels of consumption with people who generally don’t meet the criteria of a substance use disorder but are experiencing adverse effects as a result.  

Adapting SBIRT

The NeC-ATTC has provided technical assistance and implementation support to organizations seeking to integrate SBIRT in HIV programs, prevention and recovery support organizations, state agencies, and community peer-based initiatives. As such, SBIRT has been adapted to meet specific community needs. 

Based on the focus of programs and target populations, we have helped providers learn to use SBIRT to screen and address problematic behavior related to specific health issues. Creating an atmosphere that is physically and cognitively conducive to helping people feel comfortable and likely to engage is key. Validated screening tools specific to the identified health concern are used as required within the context of the SBIRT model.

A brief intervention dialogue using motivational interviewing core communication skills allows for a person-centered interaction that can help clients consider options for addressing behavior that may impede them from meeting their identified goals. A brief intervention that is effectively delivered helps to build receptivity to a referral for further assessment and possible treatment.  We have found that the components of the SBIRT intervention can be adapted to fit a variety of specific health issues beyond just problematic substance use without compromising the fidelity of the evidence-based practice.  

Expanded Application of SBIRT: Case Study

While major depression and general anxiety disorders are the most diagnosed mental health disorders in the US, they are severely underdiagnosed among the Black community. 

Although socio-economic, cultural, and contextual factors contribute to health disparities for people of color, stigmatizing beliefs about mental illness lend to the underdiagnosing of these disorders for African American populations. As such, the SBIRT model has the potential to enhance the identification of mental health issues within diverse communities.  

Currently, the NeC-ATTC is providing technical assistance support to Dr. Sidney Hankerson, Columbia University’s pilot study, “Depression Screening in Black Churches,” a clinical trial testing the viability of using SBIRT with African Americans versus the traditional mental health referral process. 

The study recognizes that African Americans have the highest rates of church attendance among all racial/ethnic groups in the U.S., with over 60% attending church several times per month. Approximately 72% of African Americans with serious personal problems, including depression, seek help in Black churches.

The pilot program recruits members of church congregations, (30 churches involved in the study) to train as Community Health Workers (CHWs) in the facilitation of SBIRT. It is hypothesized that using SBIRT may bridge the gap between depression screening and access to treatment. Part of the cultural framework for initiating SBIRT includes CHWs representative of the diverse communities who also attend the churches where the study is piloted. This offers both the faith-based and racial-cultural affiliations that can help increase the likelihood that community members will participate in the study, get screened, and possibly link to mental health care.  

Cultural Benefits of SBIRT Adaptation 

With health care disparities reported as extremely high amongst diverse populations, the flexibility of SBIRT model provides opportunities to reach diverse populations who struggle with conditions that may not necessarily be identified and treated in traditional health care processes.  

The Depression Screening in Black Churches is an ongoing study. But the hope is that data will show that SBIRT can help increase access to care for African American communities burdened with a high prevalence of depression and possibly other mental illnesses.  If so, it can open the door for more studies as well as training for clinicians and providers to help meet the needs of culturally diverse individuals and advance equity in care.

Depression Screening in Black Churches

https://clinicaltrials.gov/ct2/show/NCT04524767

Sponsor:

Columbia University

Collaborator:

National Institute of Mental Health (NIMH)

Information provided by (Responsible Party):

Sidney Hankerson, Columbia University

Author bio: Diana Padilla, is a Research Project Manager, at the New York State Psychiatric Institute, Division of Substance Use Disorders, Columbia University Medical Center. She is a curriculum developer and senior trainer for the Northeast & Caribbean Addiction and Prevention Technology Transfer Centers. She is certified by the New York State Office of Addiction Services and Supports (NYS OASAS) as an SBIRT trainer.

Embracing Change: How Northwest ATTC is Helping Programs Enhance Their Co-occurring Disorder Services – A Model for Success

By Denna Vandersloot, co-director, Northwest Addiction Technology Transfer Center

Many clients seeking care for their substance use disorder also have co-occurring mental health disorders – and vice versa. Treating both types of conditions at the same time by providing quality integrated services is more effective than treating each disorder separately.

Yet while integrated care has been increasingly prioritized, it remains an often-elusive goal. An estimated 17 million adults in the United States live with co-occurring mental health (MH) and substance use disorders (SUD), yet only 5.7% of these individuals receive treatment for both disorders (NSDUH, 2020). 

So, what is getting in the way?

• We have a divided system of care where MH and SUD services are often funded separately and governed by different administrative rules.
• There is a long list of system-, program-, clinical-, and client-related barriers to integration of services.
• “Integrated care” has become a buzzword and isn’t always clearly defined.

While the list of barriers to integrating SUD and MH services is long, providers remain interested in and committed to better serving this population, something evidenced by a group of Oregon SUD providers who signed up for a year-long Northwest ATTC and Oregon Council on Behavioral Health (OCBH) intensive technical assistance project aimed at enhancing their programs’ capacity to serve clients with co-occurring disorders.

The project was divided into phases aligning with Gregory Aarons and colleagues’ EPIS model for implementing innovative practices:

1) The Exploration phase involved securing leadership buy-in, assessing the programs’ existing co-occurring disorder services capacity using the Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index, and providing a detailed summary report with program-specific recommendations for enhancing the level of integration.

2) The Preparation and Implementation phases involved leaderships’ participation in a NIATx Change Leader Academy featuring learning sessions and monthly coaching calls with an experienced NIATx coach.

The Sustainment phase: involved delivery of a final DDCAT site review to evaluate progress and document sustainability efforts.

Participating programs worked on a variety of change projects ranging from increasing mental health referrals, to matching treatment to stages of change for both MH and SUD conditions, to increasing the availability of co-occurring disorder group counseling.

Click to watch a video testimonial on this project, produced by Northwest ATTC and the Oregon Council for Behavioral Health

For example, Grants Pass Treatment Center (ORTC, LLC) increased their identification of mental health needs and referral to MH services within the first thirty days of treatment from 14% to 72% by increasing collaboration and coordination with mental health agencies, adding MH screening, and increasing the focus on mental health issues in case consultations.

The primary goal of this project was to improve co-occurring disorder services for clients by having program leaders engage in an intensive technical assistance process that combined the use of the DDCAT Index and the NIATx process improvement model. This goal was achieved with noteworthy results. The mean DDCAT score at the beginning (baseline) of the project was 3.21; this score had increased to 3.86 by the end of the project. Additionally, at baseline, just 30% of the programs were dual diagnosis capable, while at the final review, that figure had grown to 71%.

This suggests that future clients will be offered useful, integrated services to address their co-occurring MH and SUD challenges, a very exciting outcome for all involved.

A secondary goal of the project was to collect qualitative data on the system-level barriers standing in the way of providers’ integrating care. This data was used by the Oregon Council on Behavioral Health to help advocate for additional funding to support integrated COD care. House Bill 2086 was passed by the Oregon legislature allocating $10,200,000 in funding to support the development and implementation of payment structures/models that support integration of treatment and recovery support for individuals dealing with addiction and mental health diagnoses under one payment model.

Supporting the renewed interest in integration of MH and SUD services, this project provides a model for assisting programs to align policy, practice, and training efforts to support co-occurring disorder services.

For a comprehensive list of resources designed to assist providers and others in integrating behavioral and physical health care to better address the needs of individuals with co-occurring mental, physical, and substance use conditions, check out this guide from NWATTC. 

About the author: Denna Vandersloot is the co-director of the Northwest ATTC at the University of Washington. Her work with the ATTC Network over the past 20 years includes providing leadership, training, and technical assistance services to the Northwest region.

Embracing Change: Diversity Inclusion Project Showcase (DIPS) Promotes Recovery Community Organizations

Editor's note: This post is part of the ATTC Network's "Embracing Change" series.

The work to curb the impact of opioid use disorder and other forms of addiction is diverse and expansive. However, one fundamental portion of the effort comes via Recovery Community Organizations (RCOs), which deliver needed recovery support services to community members from historically marginalized, underserved communities. 

On October 5, 2021, an array of addiction and recovery support professionals and representatives from four of the premier RCOs in Massachusetts and Connecticut joined for an event designed to spur innovative collaboration. The Diversity Inclusion Project Showcase (DIPS): Promoting Recovery-Oriented Organizations, co-hosted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the New England Addiction Technology Transfer Center (ATTC), was conceived as a platform to facilitate collaborations between RCOs serving historically marginalized communities, state leaders, policy makers, purveyors of technical assistance, and funders. The virtual meeting had an audience of more than 100 participants. 

Among the first to address the audience was Dr. Haner Hernandez, Senior Trainer for the New England ATTC. He established the tone of profound, personal connection that he and his colleagues have with their work. Hernandez noted the importance of RCOs, quoting renowned recovery expert William White, saying, “‘Recovery can be initiated in treatment, but recovery happens in community.’”

Dr. Haner Hernandez

The first two RCO representatives to speak were Louray Barton, Recovery Coach and Peer Specialist at STEPRox Recovery Center and Efrain Baez, Director of Stairway to Recovery. Barton emphasized the engagement and enthusiasm of STEPRox’s community members.

Baez discussed Stairway’s strides in offering an array of support services, as well as its enduring struggles and needs for support with obtaining adequate resources such as housing and multilingual health professionals.

Dr. Sara Becker, Director of the New England ATTC, spoke briefly about its mission and commitment to RCOs.

“We work to foster regional and national connections among diverse stakeholders,” she said.
Following Becker was Michele Stewart-Copes, Senior Trainer at New England ATTC. “To me, the opposite of addiction is connection,” Stewart-Copes said.

The next two CBO representatives to speak were Dr. Marie Spivey, Administrative Coordinator for Recovery Support Services, and Pastor Dana Smith, Director of New Life Ministries II. Each spoke about their RCO’s services, successes, and ongoing challenges.

“The Recovery Support Services is the first of this corporation (The Spott Unlimited Inc., a nonprofit service created by the Spottswood African Methodist Episcopal Zion Church in Connecticut) to launch a supportive program which is led by a recovery coach and eight to 10 recovery support assistants who are committed to work with individuals to help them find a pathway of recovery…”, Spivey said.
Smith followed her, saying, “Recovery is not a cookie-cutter kind of thing…All of us could be in the same accident, but it’s going to affect each of us differently.”

The DIPS Showcase, hosted by the New England ATTC and sponsored by SAMHSA, succeeded in highlighting the work of Massachusetts and Connecticut RCOs.

“(Community health workers) have been the unsung heroes of the pandemic, never giving up on their respective missions to save lives and lift up families,” said Nancy Navarretta, acting Commissioner of the Connecticut Department of Mental Health and Addiction Services.

Deidre Calvert, Director of the Bureau of Substance Addiction Services at the Massachusetts Department of Public Health, also recorded a personal message of gratitude for the leadership of StepRox, Stairway to Recovery, and other RCOs in her state.

“I would like to express the Commonwealth’s sincere appreciation for all of you who’ve been on the frontlines saving lives every day,” she said.

Having only introduced a few of the myriad of RCOs serving the 6-state region, the New England ATTC has plans to present similar showcase events in the future.

Encouragingly, collaborations have already occurred since the October 2021 showcase. In 2022, New Life Ministries II reached out to the New England ATTC to request intensive technical assistance to help members of the clergy learn and infuse harm reduction principles into the church community. Among the results of the collaboration were a harm reduction training workshop, production and analysis of graphic messaging, and iterative development of innovative recovery tools. The New England ATTC and New Life Ministries II are now partnering to develop a train-the-trainer curriculum focused on harm reduction in faith-based communities.

For agencies interested in participating in future showcase events, or in proposing any partnerships, please contact the New England ATTC at newenglandattc@brown.edu.

Author Bios
A native of Varnville, SC, Levell Williams considers himself a product of faith, family, and community. He gained his BA in Mass Communication from Tougaloo College in 2021. Levell is a Health Equity Scholar at the Brown University School of Public Health and is pursuing a Master’s in Public Health focused on science communication.

Dr. Kelli Scott is a clinical psychologist and Assistant Professor at the Brown University School of Public Health. Dr. Scott serves as the Evaluation Director for the New England ATTC, and works to assess the impact of ATTC training and technical assistance initiatives throughout the New England region.

SUD and Beyond: Schools Use NIATx To Improve Youth Suicide Prevention Efforts

By: Kristina Spannbauer, Great Lakes ATTC, MHTTC, & PTTC Communications Specialist

The NIATx model for process improvement was initially based on the question: Could the strategies used to improve processes in manufacturing and other industries be used to improve services in other fields, such as in substance use disorder (SUD), mental health, and educational settings? For the past 20 years, many organizations from a diverse range of professional fields have successfully used NIATx to implement change and streamline work processes. One recent success story comes from an intensive technical assistance (ITA) learning collaborative, Building Capacity for Effective School-based Suicide Prevention, sponsored by the Great Lakes Mental Health Technology Transfer Center School-based Supplement (SB-MHTTC) and the American Foundation for Suicide Prevention.

October 13, 2021, was the official start date of the four-month ITA learning collaborative. Comprised of 12 participating school districts, the overarching aim of the project was to implement effective school-based suicide prevention efforts within the schools of each district. Many team projects focused on creating or revising suicide prevention policies, establishing protocol review schedules, creating suicide crisis manuals, and increasing staff awareness of suicide prevention policies. The incorporation of the NIATx Change Leader Academy curriculum within the prolonged learning collaborative training schedule allowed the districts more time to fully develop and implement their change projects according to NIATx principles.

Learning collaborative participants Susan Kennedy and Laura Vanderheyden of the Racine (WI) Unified School District reported that throughout the October 2021–January 2022 training schedule, they were able to complete a full inventory of their district’s current suicide prevention resources, create the first draft of their Response Manual for Suicidal Crisis, and establish sustainability best practices for using and reviewing newly integrated resources and protocols in their schools.

Ms. Kennedy and Ms. Vanderheyden recommend other schools and organizations use NIATx to make significant and lasting process improvements, commenting “[NIATx] helped define a direction and provide guidance on how to achieve our goal.”

For those interested in learning more about the Building Capacity for Effective School-based Suicide Prevention learning collaborative, additional testimonials and details from the participating districts’ final presentations will be shared in upcoming blog posts. In the meantime, check out the NIATx website to discover other success stories and learn how you can use NIATx in your own work.

A Glimpse of New York State’s Program to Address Hepatitis C and SUD

Public health officials in New York State have launched a new learning collaborative aiming to integrate Hepatitis C testing and treatment into Opioid Treatment Programs. 

One of the ATTC Network's products, Guide to Integrating HCV Services into Opioid Treatment Programs, played a key role in helping launch the collaborative.

Here's our Q&A with Mehvish Bhatti, project coordinator at the New York State Department of Health's Bureau of Hepatitis Health Care, on how the program started, and how the ATTC Network was able to help.

Q.  Give us a brief overview of the new learning collaborative you are launching. What are the objectives? Timeline?

A. The New York State (NYS) Hepatitis C Learning Collaborative is a two-year initiative designed to build the capacity of substance use disorder (SUD) treatment programs to provide on-site HCV testing and linkage to care activities for clients living with hepatitis C. This will be accomplished through completion of an organizational readiness assessment to identify areas for tailored technical assistance and additional training that will be supplemented by monthly collaborative calls to discuss challenges, identify solutions, and share best practices and resources. Six SUD treatment programs have been selected to participate in the Collaborative. Each program will receive $50,000 each year for two years. The Collaborative began on April 1, 2022 and will end March 31, 2024.

Q. Why is the Learning Collaborative so important?

A. Hepatitis C is a major public health problem in the United States. Many people living with hepatitis C do not know their status. Hepatitis C can be cured. Many people with hepatitis C also have co-occurring SUDs. Among new hepatitis C cases reported in 2019, in NYS (excluding NYC) 72% of those with known risk factors reported injection drug use as a risk. The NYS Hepatitis C Elimination Plan identified people who use drugs and substance use disorder treatment programs as priority populations and settings in the work towards eliminating hepatitis C in NYS by 2030. Providing services to thousands of individuals in NYS each year, substance use disorder treatment programs are particularly well positioned to play an important role in eliminating HCV. A 2018 survey of the hepatitis C infrastructure in NYS SUD treatment programs found 60% of SUD treatment programs do not provide HCV testing onsite and only 8% offer HCV treatment onsite. This Collaborative will help prepare these programs to screen and diagnose people for hepatitis C and link them to curative treatment.

Q. Your office found the ATTC Network's Guide to Integrating HCV Services into Opioid Treatment Programs useful. How are you using that resource in this new venture?

A. The Guide to Integrating HCV Services into Opioid Treatment Programs provided us with helpful information that we used as a foundation for the resources created for the Collaborative. It served as a guide for the Organizational Readiness Assessment created to assess the readiness of the SUD treatment programs to integrate hepatitis C services. Furthermore, the components in the guide provided a strong foundation for us and will serve as a resource when providing technical assistance to the programs in the Collaborative. This guide will also be shared with our programs so they can use it as a resource when needed.

Q. Is this the first time NYSDOH has used an ATTC product? If so, how did you find it? If not, what other resources has ATTC provided that you found useful in your efforts?

A. ATTC has several useful Hepatitis C resources that have been used by NYSDOH staff and shared with community partners. The Motivational Interviewing to Address Hepatitis C resource was shared with trainers and curricular developers who are delivering Motivational Interviewing training for NYSDOH funded programs. HCV Snapshot: An Introduction to Hepatitis C for Health Care Professionals was disseminated by the NYS Technical Assistance Center for State Viral Hepatitis Coordinators – a 2007- 2015 CDC-funded project. SAMHSA’s TIP #53: Addressing Viral Hepatitis in People with Substance Use Disorders is a foundational document for working with SUD treatment programs and will be used for the Collaborative.

Mehvish Bhatti is the Project Coordinator at the New York State Department of Health, Bureau of Hepatitis Health Care. She joined the Bureau in November 2021 to lead the HCV Learning Collaborative. 

Prior to joining the NYSDOH, Mehvish was the Public Health Planner at the Albany County Department of Health, Division of Emergency Preparedness. She has a Master’s in Public Health from the University of Albany.