Maria A. Wamsley, MD Professor of Clinical Medicine UCSF School of Medicine Scott Steiger, MD Nathaniel Gleason, MD Katherine A. Julian, MD Patricia O’Sullivan, EdD Michelle Guy, MD Jason Satterfield, PhD Funding: SAMHSA grant U79T1020295 Barriers exist to implementation of SBIRT into clinical practice ◦ Provider knowledge and skills ◦ Time pressures in the clinical setting ◦ Lack of referral resources SBIRT curricula can address knowledge and skills ◦ Improved knowledge, attitudes, confidence1,2 ◦ Improved performance on standardized patient assessments3,4 Does Shows Knows How Knows Chart-Stimulated Recall (CSR) Uses medical record to stimulate learner recollection of the encounter and explore rationale behind clinical decisions5 Electronic Health Record (EHR) Tools Ready access to knowledge at the point-of-care Reinforce previously learned skills Facilitate documentation Provide tailored resources How do residents use SBIRT skills in clinical practice as documented in patient charts? How do residents think about SBIRT as revealed through a chart stimulated recall? How do residents use EHR SBIRT clinical tools in practice? 5 hour curriculum for primary care internal medicine residents (PGY2/PGY3) ◦ Intro to SBIRT ◦ Brief Intervention/MI skills ◦ Pharmacologic management of addiction EHR Tools ◦ History of Present Illness (HPI) ◦ Assessment and Plan (A/P) ◦ Patient Information Resources (PI) Patient List 3 Patients (drinking at or above recommended limits) Faculty completed 24item checklist CSR with faculty member One-on-One meeting with faculty member Structured interview guide ◦ ◦ ◦ ◦ ◦ ◦ Identify barriers to addressing alcohol use Where alcohol fit into visit priorities Resident assessment of alcohol use Whether BI strategies were used Use of EHR tools How resident would approach case differently in future Feedback provided to resident Percentages calculated for each checklist item Qualitative analysis of CSR interview notes ◦ Generated preliminary code list ◦ Subset of notes coded and code list refined and finalized ◦ All notes were double-coded by two faculty members 20 PGY2 and PGY3 residents participated in the curriculum 18 participated in the CSR 38 charts met eligibility criteria and were included in the study 90 80 70 60 50 40 30 20 10 0 Resident Knowledge Patient Systems Denial Lack of honesty Time Medical Comorb Skills Mental Health Comorb Willingness to engage Unaware of patient drinking Social factors Medical Comorbidities Mental Health Comorbidities Medication interactions with alcohol Setting goals with the patient Linking alcohol use to medical issues Responding to change talk Approach in Future Visits Raise alcohol Link alcohol to medical/mental health Use BI strategies Use EHR tools 5 residents (28%) used at least one EHR tool ◦ 3 charts HPI tool ◦ 2 charts A/P tool ◦ 5 charts PI tools Use of tools ◦ Provision of tailored resources to patients ◦ Criteria for SUD ◦ Elements of appropriate plan Barriers to use ◦ Unaware ◦ Not part of regular workflow More intensive training with opportunities for practice and feedback may be required to improve brief intervention skills. Additional reinforcement including simulation to practice integration of EHR tools is essential to their usefulness. CSR is a potentially useful tool to: ◦ assess curricular interventions ◦ reinforce curricular materials ◦ provide individualized feedback Single institution CSR was not recorded Dual role of faculty performing CSR Residents identified patients for discussion CSR used as a summative tool 1. 2. 3. 4. 5. Bernstein E et al. An evidence based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Subst Abus. 2007;28(4):79-92. Seale JP et al. Skills-based residency training in alcohol screening and brief intervention: Results from the GeorgiaTexas “Improving Brief Intervention” project. Subst Abus. 2012;33(3):261-271. Satterfield JM et al. Using Standardized Patients to Evaluate Screening, Brief Intervention, and Referral to Treatment (SBIRT) Knowledge and Skill Acquisition for Internal Medicine Residents. Subst Abus. 2012 ;33 :303-307. Wamsley MA et al. Team-Based Learning Exercise Efficiently Teaches Brief Intervention Skills to Medicine Residents. Subst Abus, 2013;34:344-349. Schipper S, Ross S. Structured teaching and assessment: new chart-stimulated recall worksheet for family medicine residents. Can Fam Physician 2010;50:958-59.