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The implementation process began with adminstrators to provide them with an understanding of SBIRT. Then, moved into conducting an analysis of the organization that SBI would be implemented into. We completed a walk through as if we were patients, talking with all direct line and ancillary staff about SBI, noting their ideas, feedback and suggestions of how to implement. This resulted into an implementation plan that was shared with direct line staff and administration at each site. Part of the plan incorporated training that needed to occur for each person involved in the project and the lead person for SBIRT at the site. Upon approval of the plan, implementation began.

Due to the uniqueness of each site, a different plan was created (no cookie cutter method worked). Initial implementation included didactic training and group exercises. Particularly in the family residency programs, SBI was reinforced by preceptors and by SBIRT staff. Both medical students and residents received hands-on clinical development training by conducting real screening and interventions with patients while either videotaped or observed in person. SBI refresher courses were completed through noon conferences or other in-house training events.

Another unique feature was implementing SBI with pregnant women in a large hospital. What we learned is that screening pregnant women has to be different that screening the general adult population. Because pregnant women that are using substances are often highly guarded, to screen using Q-F questions or 30 day max produced less than appealing results. This led to a complete revision to the project that led to a delay in the implementation process, which was further delayed by the hospital transitioning to an EMR for the clinic.

in process

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Training residents to perform SBI takes time and help of behavioral staff in order to develop the clinical abilities to conduct SBI. It goes beyond the didactic lecture and an integral part of how they practice.

We soon discovered that about 12-15% of the patients were receiving a BI and only about 1-3% needed referred to treatment. Two other intersting things resulted from this: 1. Patients were requesting referrals to mental health counseling as opposed to substance abuse treatment ("I drink because I am depressed, not cause I have an alcohol problem")and 2. patients did not always want to go into formalized treatment or Brief treatment if it was at another location. Those that accepted the referral were in need of detox or residential treatment. Therefore, we had to create the "safety net" for those that did not enter treatment and worked with the patient using MI and other strategies to acheive their goals with regards to substance use. We worked to help them acheive their goals and if they could not, then try again to get them into treatment. And we established a relationship with a treatment agency that worked with patients that had both MH and SA issues.

Using the organizational strategy helped during the implementation. Originally this was not part of the plan, but it made implementation alot smoother for subsequent sites. It helps to determine who the key people are in SBI, who does what-when-where and how (which is the feedback given from those that will actually be doing SBI)and who will ultimately be responsible for overseeing SBI gets done.

Screening pregnant women with an appropriate screening tool led to an increase in identifying women at-risk of using alcohol during their pregnancy (which was the target population).

unpublished

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