Oregon team creates curriculum tackling SBIRT implementation in primary care

Google “SBIRT projects” and you’ll find lots of federally-funded efforts to learn about service delivery models for SBIRT in various settings. And there are more coming down the pike.

sbirt-logoThat’s because research has firmly established SBIRT’s effectiveness in reducing alcohol use and evidence is building that it reduces drug use. Favorable cost-benefit analyses are also piling up, affirming the commonsensical notion that prevention and early intervention reduce healthcare costs and other burdens borne by taxpayers, particularly in the area of criminal justice.

One such federally-funded project is SBIRT Oregon, based in Portland at Oregon Health and Sciences University (OHSU). The story of SBIRT Oregon is one of evolution.   Originally conceived as an educational grant, its primary focus was the development and dissemination of a training curriculum about the use SBIRT in primary care. As it unfolded, however, SBIRT Oregon became a project about implementation, since that’s where many of SBIRT’s questions and barriers are located.

SBIRT Oregon was born in 2008 when OHSU, along with 11 others, received a SAMHSA Medical Residency Cooperative Agreement.

The five-year project trains medical residents about SBIRT’s application in primary care.   It targets most of the family, internal and preventive medical residencies in Oregon, with the ambitious goal of training the majority of primary care physicians entering the state’s workforce between 2009 and 2014.

The People

John Muench

John Muench

SBIRT Oregon’s Principal Investigator is John Muench, MD, MPH, a primary care physician who said he’d seen many patients with drug and alcohol problems in a variety of clinical settings.

Jim Winkle MPH

Jim Winkle

“I became interested in finding better ways to address unhealthy substance use,” he said. Systemized screening and brief intervention approaches seemed to be the most patient-centered.”

The Project Director is Jim Winkle, MPH, who had previously trained clinicians in primary care to recognize and address intimate partner violence.

Muench and Winkle also connected with Denna Vandersloot, MEd, Director of the Northwest ATTC, who joined the SBIRT Oregon team as a subject matter and technology transfer expert.

The Project

“We didn’t want residents to receive training and then go into environments that weren’t conducive to using it.”

Early in the development of the SBIRT curriculum, team members realized the project needed a companion “clinic process” curriculum to guide the process.
“We decided to set up a systemized SBIRT process to implement in the residency clinics,” Muench said, of integrating this evidence-based practice into clinical practice.

He and other team members opted to provide trainings and assist with implementation in seven clinics simultaneously, so that residents could immediately apply their newly-learned skills in clinical settings.

“We didn’t want residents to receive training and then go into environments that weren’t conducive to using it,” Muench said. “So the project became much more about implementation than it was originally planned to be.”

The clinic process curriculum focused on clinic flow, the use of electronic health records, and especially the importance of involving the clinic’s entire staff in the SBIRT process, not just the medical residents.

In fact, a unique feature of SBIRT Oregon is that medical residents don’t do the screening—they perform the brief intervention when indicated. Unlike some SBIRT delivery models, in this case the front desk staff administers a brief screening at check-in and medical assistants deliver a full assessment form  to patients who score positive.

“By the time the physician gets into the room, the patient’s completed AUDIT [Alcohol Use Disorders Identification Test] or DAST [Drug Abuse Screening Test] is included in the medical chart,” Muench said.

clinic flow

SBIRT Oregon’s innovative clinic flow, available at sbirtoregon.org
Muench and Winkle attributed the all-around positive response to SBIRT among staff to their whole-clinic team approach of implementation and to the effectiveness of motivational interviewing methods for brief interventions.

“I think the students came in with mixed attitudes, but they were very receptive to SBIRT once they realized they were going to be armed with specific skills, particularly MI,” Winkle said.

Going Forward

The SBIRT Oregon project is set to run through 2013. What’s next for Muench and Winkle? The Affordable Care Act has made SBIRT in high demand.

“SBIRT is now one of the incentive measures for a CCO [Coordinated Care Organization], so clinical systems are asking us how they can best implement it,” Muench said.

They are also looking harder at electronic health records.

“We have found that the EHR can be either a facilitator or a barrier to SBIRT being done,” Muench said.  “So we’re working on how to help EHR vendors move toward a product that fits with SBIRT.”

Although the grant will end this year, SBIRT Oregon’s high quality training material will continue to be freely available to the public.  This includes downloadable tools for practice like pocket-sized readiness rulers, an online training curriculum with demonstration videos and role-play exercises, and a guide to clinic flow.

Recently, SBIRT Oregon released a concise patient testimonial video that’s part of their medical resident curriculum and free for use in any SBIRT training.

SBIRT Oregon’s recently-released training video features patients describing how their doctors assisted their recovery.

“It’s a training tool to show residents that there is hope for even patients with the highest degree of substance use dependence, that they can recover and stay sober,” Muench said. “We found patients who explained in their own words how their doctor played an important role.”

They have found it effective in helping to change attitudes.

“You can teach with all the data and all the evidence in the world, but a few good stories seem to trump everything,” Muench said.

Visit SBIRT Oregon’s website to learn more about their free products and the services they offer primary care clinics throughout the state at  sbirtoregon.org

Additional Resources

Webinar Presentation: Introduction to Screening, Brief Intervention and Referral to Treatment from the ATTC Network – Overview presentation, includes lessons learned from SBIRT Oregon

SBIRTwiki – a great collection of information and resources; join this wiki!

SBIRT on ireta.org – key resources, categorized links, and a Toolkit for Practice

The SBIRT Alert subscribe the SBIRT-ATTC’s occasional e-newsletter