Bridge Video Talk Show Recap: Getting Physicians on Board with SBIRT

May 21, 2014

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

In the Spring 2014 issue of the The Bridge, the editorial board explores SBIRTas a way to promote the integration of substance use treatment into mainstream medical care.

Articles in this issue reflect their responses to the question posed by editor Paul Roman: “What could each of us be doing to enhance the spread of physician involvement in SBIRT?”

I had the privilege of moderating a discussion of Bridge editorial board members Mike Boyle, Louise Haynes, and Paul Roman during the Bridge Video Talk Show on May 20. They talked more about their views on getting primary care physicians on board with SBIRT. 

(The session will be available as a podcast—watch your email or the ATTC Network website for details.)

A few highlights from the show:

Lessons from EAP programs. Paul Roman talked about how executive leaders in business and industry were slow to adopt EAP programs until these programs were presented as a way to take a "problem" off a supervisors’ hands. The problem, of course, was an employee whose absenteeism or performance issues suggested the need for substance abuse treatment. Expanding EAP programs to include other problems that could be affecting attendance or performance also increased buy-in from executive leaders. EAP programs were successful when they solved a problem for employers. Would physicians embrace SBIRT more widely if they perceived it as solving a key problem? (Hmmm…do I hear a NIATx principle here?)

Financial considerations often drive adoption of new practices. Louise pointed out that The Medicare Hospital Readmissions Reduction Program (HRRP) established in the Affordable Care Act provides a financial incentive to hospitals to lower readmission rates. SBIRT in hospital settings has the potential to decrease expensive readmissions; maybe this would help to spread use of SBIRT.  Paul added that by getting people into treatment sooner, SBIRT offers physicians a way to reduce or prevent the expensive medical complications that so often accompany and are exacerbated by substance abuse.

What would Everett Rogers do? As we discussed dissemination strategies, Mike Boyle wondered why we haven't done a better job doing what research tells us works in terms of disseminating and adopting new practices.

Hello! I jumped up and grabbed my dog-eared copy of Roger’s Diffusion of Innovations text.

Here’s what we know and have known about innovation for years and years:  

• It has to meet a need or solve a problem or do something better than what we have now. We didn’t need iPhones, for example, but they did so many cool things we couldn’t do before that they’ve been widely adopted.
• It has to be easy to adopt.
•  It really helps to to see other people using it and to copy what they are doing.

While I think SBIRT can offer all of these things, it isn’t necessarily portrayed that way.

Also, Mike and Paul both mentioned the idea of using a deliberate dissemination strategy that incorporates opinion leaders. Several audience members raised this issue. How many doctors do we have doing training and recommending that their colleagues do SBIRT?  Does it feel to physicians that people without knowledge of their daily practice are imposing an expectation on them? And isn’t that stuff part of what the nurse, not the doctor, does anyway? Why aren’t we selling nurses on the idea?

So…what do you think? If SBIRT is a key to integrated care, what do we need to do differently to have wider adoption?  For more information on SBIRT, visit the website of the National SBIRT ATTC -- there may be an SBIRT training coming up in your area soon.

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.

May is Hepatitis Awareness Month: ATTC Training Resources

May 14, 2014

Maureen Fitzgerald
Editor, ATTC Network Coordinating Office and NIATx

New medications now available and those coming to market for treatment of hepatitis C are the topic of this month’s (Thursday, May 15, 2014) Third Thursday iTraining: “Hepatitis C Treatment: What do I use?” Presenter Bruce Burkett, Executive Director and Founder of the HepC Alliance, will talk about the medications currently available, their success rates, and issues related to access to and cost of the medications.

The iTraining complements the feature article “Availability and Use of HCV Services in Substance Use Treatment Settings” in this month’s ATTC Messenger, written Meg Brunner, Librarian for the Clinical Trials Network (CTN) Dissemination Library. Brunner shares the results of two health services research studies on the hepatitis C virus (HCV). These studies, conducted by the National Drug Abuse Treatment CTN, identified the need for the substance abuse treatment system to increase screening, counseling, and information services for patients with or at risk of contracting HCV.

To help meet that need, the National ATTC Viral Hepatitis Workgroup will soon be offering online and face-to-face options for training on HCV. The workgroup includes representatives from each of the 10 regional centers and is developing HCV training products specifically for Federally Qualified Health Centers (FQHCs). The courses target staff at FQHCs but are open to anyone interested in learning more about HCV prevention and treatment.

The first product is a 90-minute introductory online course that will be available in late summer 2014 on the ATTC HealthEKnowledge site. It consists of four modules covering: 1) populations at risk; 2) an introduction to the disease; 3) screening processes; and 4) treatment options. In addition, each regional ATTC is gathering region-specific HCV resources that will be incorporated into a Regional Resources section at the close of the course. The online course is expected to go live later this summer.

A second face-to-face training option, modeled on the online course, will offer more in-depth training on HCV. “It’s designed to build on the HealthEKnowledge course and targets behavioral health providers at FQHCs,” says curriculum developer Diana Padilla, Cultural Proficiency Program Manager for Training at National Development and Research Institutes, Inc.

"While the online course presents an overview of HCV, the face-to-face training will provide a more comprehensive review of the epidemiology of HCV and its impact on society, and risk groups,” says Padilla. “It will also promote screening and diagnostic testing and will discuss treatment options and linkage to HCV health care, which varies from region to region.”  The face-to-face training will include a section on telemedicine and telehealth options in rural and remote areas of the country. “We are planning to pilot a first draft of the training in July, with Training of the Trainer events to follow later for all the regional centers,” says Padilla.

Watch your email or check the ATTC website for more news about these new training resources from the National ATTC Viral Hepatitis Workgroup!

Converting crisis calls to treatment: Tips from the Iowa Office of Problem Gambling Treatment and Prevention

May 6, 2014

Maureen Fitzgerald

Editor, ATTC Network Coordinating Office and NIATx

Webinar 3 in the  ATTC Network’s Problem Gambling Webinar series on Thursday, May 8, 2014,  features Dr. Nancy Petry, who will be discussing changes to the DSM5 and how they'll affect treatment for problem gambling.
The webinar series a great lead-in to the 11^th Annual Midwest Conference on Problem Gambling and Substance Abuse: Prevention, Treatment & Recovery in an Era of Change (June 25-27, 2014, Kansas City).
 
The Mid-America Addiction Technology Transfer Center sponsors this event in partnership with addiction treatment and problem gambling treatment programs from Iowa, Kansas, Missouri, Nebraska, and Oklahoma. The conference features national experts on problem gambling—the 2014 agenda includes Dr. H. Westley Clark and Dr. David-Mee Lee, among others—along with updates from the states on their problem gambling initiatives.

The Iowa Department of Public Health (IDPH) Office of Problem Gambling Treatment and Prevention (IGTPP) has presented regularly at the conference. Their presentation at the 2013 conference shared the results of their project to convert crisis calls to treatment through a series of NIATx change projects.

A few facts about Iowa: In 1986, Iowa was the first state in the country to establish a state-funded gambling treatment program. A portion of gambling profits from casinos and the state lottery were allocated for problem gambling treatment. In 1987, Iowa became the first state to offer 1-800-BETS OFF, a free state-wide problem gambling helpline. That helpline receives 4,000 calls per year. Today, Iowa is home to 18 casinos licensed by the state’s Racing and Gaming Commission, three tribal casinos, 2,400 lottery outlets, 3,350 social and charitable gaming licenses, along with many Internet and other illegal gaming. Gambling is easily available in any one of the state’s 99 counties.  IDPH contracts with 11 local treatment agencies to provide problem gambling prevention, treatment and recovery support services in 11 service regions across the state.

NIATx has been widely used in Iowa's substance use treatment organizations; from 2005 to 2007, the state was party of a CSAT-funded state/payer pilot project to test NIATx strategies to improve access to and retention in substance abuse treatment. Iowa providers across the state continued to participate in NIATx projects in subsequent years. A project launched in 2009 applied NIATx change strategies to the state’s problem gambling program. Bob Kerksieck, Health Facilities Surveyor IGTPP shared results of that project at the 2013 Midwest Conference on Problem Gambling.

100 walk-through phone calls: To get an idea of how Iowa’s funded gambling treatment programs were responding to Bets Off Helpline referrals, Kerksieck, along with the project coach Janet Zwick and Mark Vander Linden (then program manager for IGTPP), made more than 100 phone calls over a one-year period to the helpline, posing as problem gamblers.

This exercise provided a wealth of information.  “Many calls went well, but on the first round, one-third of the calls didn’t get through to anyone at the program. Some might have gone better. Some messages were never returned,” says Kerksieck.  And for the majority of the cases, there was no counselor available within two days of the call.

Eric Preuss, current program manager at IGTPP, recommends that any agency interested in starting a NIATx change project start with the phone-walk through. “The first phone call is especially critical for problem gamblers. Most problem gamblers present as crisis callers, so engaging them on the phone when they’re seeking treatment is critical.”

Based on the data gathered from the 100 phone walk-throughs and other activities, the change team tested implementing a “warm handoff” from the 1-800-BETS-Off helpline directly to treatment programs, for all calls made from 8am to 8pm, Monday-Friday.

In a warm phone hand-off, a caller gets connected directly to a counselor at a treatment program. Instead of giving caller’s the phone number to call a local treatment program, or transferring the caller and hanging up, the helpline would transfer the caller and stay on the line, telling the program, “Hello, I have Jane on the phone. She called about a gambling problem and would like to talk to someone. Do you have a counselor available who can talk to him/her?” 

“Before this change, 57% of callers asking for help were actually connecting with a live person at a treatment agency,” says Kerksieck. “After this change, that number increased to 83%.”

Adds Preuss, “We’re encouraging our programs to have a counselor available to handle problem gambler crisis calls 24/7. We recommend no waiting and no call-backs, and contracts now have a minimum requirement that a qualified counselor responds to a helpline call within 90 minutes of the initial call, 24 hours per day and 7 days per week.”  

Preuss and his team continually evaluate the phone answering processes. A recent NIATx change project took a look at calls that appeared to be originating from outside the state of Iowa. These calls were automatically forwarded to the national problem gambling helpline.

“We learned that many of those callers were actually Iowa residents using mobile phone numbers with non-Iowa area codes,” says Preuss. “We decided to unblock the out-of-state callers and then saw a 25% increase in callers.”  As part of a this change project, Helpline staff now ask callers to identify what state they’re calling from, and if from Iowa, what county. “We can then refer people who are calling from out of state to an appropriate resource in their area.
  

Kerksieck’s 2013 conference presentation also shared results of a NIATx change project to reduce intake paperwork. “In the first year of our NIATx problem gambling project, we also took a look at the problem gambling screening tool our providers were using. The most common screen at the time was a 20-question screen, which was just too long to get substance abuse treatment programs to adopt,” says Kerksieck.  After testing other screening tools, the department selected the BBGS screen, a three-question test that has been endorsed by researchers and the National Center for Responsible Gaming (NCRG). This resulted in a significant increase in problem gambling referrals from substance abuse treatment programs that adopted the BBGS.

(Read how Substance Abuse Services Center (SASC) in Dubuque, Iowa decreased assessment paperwork and increased client admissions to gambling treatment by 164%.)

A shorter screen was one of the changes that helped streamline the intake process, says Preuss. “The net effect of the project reduced paperwork at treatment programs from up to four hours for an intake to less than one hour.”  However, it appears that some programs are increasing the amount of paperwork for an admission. “This would be a prime area for a NIATx booster with programs,” he comments.

The Iowa programs are also encouraged to keep time slots open the next day for problem gamblers who call the night before. Some programs still have problematic waiting lists for both substance abusers and problem gamblers.  “Our NIATx data informed us that this is more problematic for problem gamblers because their referral is usually crisis-oriented and not forced by corrections, employer, etc.” says Preuss. “If the crisis has passed, the client is more likely to no-show.” 

One of the most successful changes tested was offering the first four sessions free of charge.

 “Our contracts mandate programs offer a sliding fee schedule, but allow the programs to decide how to set their sliding fee schedule,” says Kerksieck. “By the time you’ve got the nerve to call a helpline, you’re usually in severe financial straits and may balk at having to pay for those first sessions. We figured that these people had already paid a huge down payment on their treatment, since their gambling losses were in part funding our treatment programs.”

Kerksieck added, “All the programs that used this NIATx change cycle got a significant bump up in both admissions and continuation by offering the first four sessions free. One program reported a 300% increase in admissions and one of the larger programs found that continuation (attending at least 4 sessions in the first 30 days of treatment) increased from 57% to 100%. ”

Preuss and Kerksieck are optimistic that the DSM-5’s new definition of problem gambling as an addictive disorder will increase awareness of problem gambling as a co-morbid condition. They’ve also noted changes in Medicaid, either due to the new definition or the ACA, leading to an increase in reimbursements for problem gambling treatment outside of current state funding. 

To find out more about how the DSM-5 changes for gambling will affect treatment, attend Webinar 3 in the ATTC Network’s Problem Gambling webinar series, this Thursday, May 8. Dr. Nancy Petry was a member of the American Psychiatric Association's Substance Use Disorders Workgroup for the DSM-5, and she led the subcommittee on behavioral addictions. In this webinar, she will outline the changes to gambling diagnosis and describe their impact for other behavioral addictions. She will also outline how the changes for gambling diagnosis are likely to impact the assessment and treatment of gambling problems in years to come. 

Preuss says that the potential increase in clients seeking treatment for problem gambling underscores the need for the department and contracted providers to continually examine their processes. “We ask for regular feedback from providers on how their systems are working,” he comments. “The NIATx tools are used by providers to continually monitor and improve access to problem gambling treatment services ”

 NIATx has been a “win-win” for providers and those seeking problem gambling treatment services, concludes Preuss. “Integrating the NIATx philosophy and tools into IGTPP has improved client access to care, and has given us a foundation for continual process evaluation and improvement. Every program wants to increase client admissions and continuation.”

For more information on the Iowa’s Office of Problem Gambling Treatment and Prevention (IGTPP), contact:

Eric M. Preuss, MA, IAADC, CCS

Program Manager
Office of Problem Gambling Treatment and Prevention
Iowa Department of Public Health
Division of Behavioral Health
eric.preuss@idph.iowa.gov

Bob Kerksieck, LMSW, IAADC

Health Facilities Surveyor
Office of Problem Gambling Prevention and Treatment

Iowa Department of Public Health

Division of Behavioral Health

Robert.Kerksieck@idph.iowa.gov

Managing Benzodiazepines with MAT: The Philadelphia Story

April 14, 2014

Maureen Fitzgerald

Editor, ATTC Network Coordinating Office and NIATx

With this month’s Third Thursday iTraining (2:00pm EST, April 17, 2014) coming up, “Management of Benzodiazepines in Medication-Assisted Treatment,” I took a few minutes to chat with Roland Lamb, Director of the Office of Addiction Services at Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS).

Lamb and colleagues at DBHIDS got the ball rolling to create a set of practice guidelines for benzodiazepines back in 2011, in response to what they saw as a very confusing environment for Philadelphia providers and their constituents. 

“We were seeing a lot of different approaches to benzodiazepines and MAT for opioid dependence,” says Lamb. “Some providers were medicating patients with benzodiazepines and others refused to treat anyone who was using them. There were also providers who just didn’t know what to do with patients who continually tested positive for benzodiazepines while receiving MAT. And then there were patients who were getting prescriptions for benzodiazepines but not testing positive—so they must have been dealing. It was a very confusing environment for providers and for patients, but our main concern at DBHIDS was that we did not want to see people discharged from treatment for the very reason they needed treatment.”

A suggestion from Dr. Trusandra Taylor led Lamb to consider creating a resource similar to the ATTC buprenorphine treatment blending product. He then reached out to Dr. Arthur Evans, Commissioner of DBHIDs, Dr. Matthew Hurford, Chief Medical Officer at DBHIDS, Dr. James Schuster, Chief Medical Officer at Community Care Behavioral Health Organization, and Mike Flaherty, then director of IRETA, to get the project going.  Drs. Hurford and Schuster, along with Dr. Dawn Lindsay of IRETA, will present the April 17 iTraining.

“We saw this as not just a Philadelphia problem, but a statewide and national problem,” says Lamb. “The end result we hoped would be a set of guidelines that would focus on treating the person rather than managing the medications.”

The resulting guidelines, developed by IRETA, join the of Practice Guidelines for Recovery Oriented Treatment that DBHIDS has created as part of its Tools for Transformation initiative. Jessica Williams provides a great overview of the guidelines in her article in this month’s ATTC Messenger. For more about the Transformation Initiative, see Jon Korczykowski’s recent story in Behavioral Healthcare, "Transformation in Philadelphia". 

“Philadelphia providers have welcomed the benzodiazepine guidelines, but at the same time they’ve given some providers reasons to question use of benzodiazepines. We still need to figure out how to fit this all together in terms of risk management,” says Lamb. “We’re hoping that providers will begin to tell us which guidelines are useful, and we also want to hear from those they’re treating.”

Overall, says Lamb, creating the guidelines demonstrates how payers like DHBIDS can enhance quality of care. “Partnering with providers serves our constituents better, and creating guidelines like these allows us to extend the partnership with greater continuity.” 

Alcohol Awareness Month and Technology

April 2, 2014

Dave Gustafson, Ph.D.

Director, Center for Health Enhancement Systems Studies (CHESS) and NIATx

This April marks the National Council on Alcoholism and Drug Dependence’s 28^th Alcohol Awareness Month, “Help for Today. Hope for Tomorrow.” NCADD devotes this month every year to reducing stigma and increasing awareness about alcohol addiction. NCADD’s message is that alcoholism is a serious illness and not a choice. This year’s theme on preventing underage drinking is a reminder about starting early in educating our children on the dangers of alcohol abuse.

What’s interesting to me is that probably a lot more people are hearing about Alcohol Awareness Month today than back in 1987, when NCADD started the campaign. In 1987, radio, TV, and print media were the main ways to build awareness.

Today, the Internet and social media are spreading NCADD’s message faster and farther. Through Facebook, Twitter, and email, more people in more places can participate easily in alcohol awareness discussions and activities. My guess is that this translates into an exponential increase in awareness and activities and that more schools, parents, churches and communities will be getting the word out.

The Internet is an incredible tool for sharing information, and with technology changing at breakneck speed we may be at just the start of huge technological innovations. I’ve heard that we are in the first minute of the first day of the digital revolution. It’s hard to even imagine what might be in store for us just a year from today.

Public information campaigns like Alcohol Awareness Month use the Internet to increase awareness. But increasing awareness doesn’t solve the problem. We need to equip people with effective tools to manage their chronic conditions. How do we do something about the problem once we’ve raised awareness?

And here again, Internet technology offers an answer. 

Back in 2003 when we started to look at ways to improve the treatment system—with the Robert Wood Johnson Foundation grant that created NIATx—I talked to a lot of researchers and policy makers who said that the problem was “not enough people.” There also seemed to be a general feeling that having more counselors would give more people access to treatment. 

But as an engineer (stay with me now), my first thought was that addiction treatment is incredibly labor-intensive, and that almost any industry that builds things (I was thinking of treatment as a product) doesn’t ask, “How can we get more people?” They ask instead—“How can we do more with what we already have?”

 

I never thought that “more people” was the answer to improving the addiction treatment system. I thought we needed to ask different questions: “How can we supplement the work that people are already doing? How can we reduce repetitive tasks? How can we use other existing resources to meet our goals?”

Don’t get me wrong—people are great. (I’m even married to one and she’s pretty wonderful.) But they have limited memory and have to deal with competing demands like eating and sleeping and even taking a vacation now and then. And in the treatment field (as in other fields) counselor skill and the quality of care they provide varies.

Enter the Internet. While some have raised concerns about new mobile health systems reducing or eliminating the human factor, the Internet actually supplements the human factor.  People suffering from alcoholism and other SUDs need emotional and social support to recover. A counselor can provide some of that support once a week or so—but an Internet-based social support group makes it available 24/7. Now it’s possible for a teen in small Iowa farming community to connect at any time of day or night with someone in his support network of people of different ages and backgrounds from across the country, all united in their goal to embrace a life in recovery.

That’s just one example of how technology is really a facilitator, an extension of the human support that a counselor and groups such as AA provide. With unlimited time and energy, technology is an addition, not a replacement.

NCADD’s Alcohol Awareness Month reminds us that alcoholism is a chronic disease; like other chronic conditions it requires using various resources to make a difference. Technology-based tools increase the resources available to help people manage their conditions. These rapidly evolving innovations offer great potential to combat the devastating consequences of alcohol and other drugs on individuals, families, and communities.   

David H. Gustafson, Ph.D., is Research Professor of Industrial and Systems Engineering at the University of Wisconsin-Madison and director of the Center for Health Enhancement Systems Studies, which includes NIATx. His interests in decision, change, and information theory come together in the design of systems and tools to help individuals and organizations make effective changes. Dr. Gustafson leads a research team that has developed A-CHESS, a smartphone-based health system for recovery support and relapse prevention.