**SBIRT at ACCESS**

**Program Description**

Access Community Health Network (ACCESS) is designated federally qualified health center (FQHC) operating an integrated network of 50 community health centers in medically underserved, low-income metropolitan Chicago neighborhoods. Each year we serve more than 215,000 medically underserved patients in the metropolitan area.

Because of our breadth and reach, we are able to support multiple medical residency programs where residents learn medicine in a community health setting. Currently, we have over 50 residents from different residency programs at our health centers. Yet, we know that the patients we serve require an in-depth knowledge of multiple areas not the least of which is substance abuse treatment. ACCESS is uniquely positioned to assist residents throughout the region learn how to address addictions issues in their patients. There are two overarching goals of SBIRT at ACCESS:

1. To provide a systematic way to train physicians on the impact of substance abuse on health and to attune them to the possibility of substance abuse in their patients. 

2. To provide patients who may be addicted to alcohol or another drug with a medical home where they can be supported in treatment by their physician. 

Through SBIRT at ACCESS we will teach medical residents evidence-based models for screening, brief intervention, referral and treatment. The curriculum and implementation provides opportunities for "hands-on" lessons where residents work with patients who are at-risk for substance abuse or who may suffer from addictions, under careful supervision of attending physicians. The curriculum is being fully documented for replication in other health systems, residency programs and institutions throughout the region. A unique feature of this program is the emphasis on the use of SBIRT in a community health setting and the incorporation of practicum in the community health setting. All residents trained are completing their clinical rotation in Community Health Centers designated as Federally Qualified Health Centers ( FQHC). The majority of ACCESS health centers are in areas of Chicago where substance abuse is significantly higher than the national average.

Access Community Health Network (ACCESS) is a network of 50 federally qualified health centers and serves 215,000 patients, including 69,000 uninsured patients, each year throughout the Chicago metropolitan area. All of the health centers in ACCESS network are located in medically underserved communities. The vast majority of our patients are 200 percent below the federal poverty line and nearly 50 percent are Medicaid beneficiaries. Approximately 90 percent of patients are either African-American or Hispanic. 

ACCESS Community Health Centers where medical residents complete their clinical rotation. In the first year, the primary location for training and implementation will be: Madison Family Health Center, 3800 W. Madison Ave., Chicago, IL. 60624.

The training targets will target medical residents who are completing rotations at one of ACCESS 50 community health centers throughout the Chicago metropolitan area. There are five residency programs who are currently slated to incorporate the training into their medical residency program: Mount Sinai Family Practice Residency Program, Jackson Park Hospital Family Practice Residency, Mount Sinai OB/GYN Residency Program, University of Chicago Internal Medicine Residency Program and University of Chicago OB/GYN Residency Program. Eventually, any residency programs affiliating with ACCESS will be using this as part of their training. In addition to the medical residents, attending physicians at ACCESS and non-physician staff throughout ACCESS will be trained on SBIRT. 187 medical residents and 80 other health professionals will be trained during the life of the grant.

**Program Model**

The trust and partnership that exists between primary care physicians and patients is a key factor in expanding the role of primary care physicians in screening for early disease detection and early intervention. In this context, Access Community Health Network seeks to provide "medical home" for its patients - assuring a full continuum of care for those that come to ACCESS.

SBIRT at ACCESS builds on this vision - screening and brief intervention as well as referral to treatment is part of the daily practice of physicians. It is one component of assuring that all patient needs are met and that intervention in potentially chronic diseases happens early. 

Within this context, and with a keen eye towards the fact that residents will be practicing SBIRT in ACCESS community health centers, the curriculum is being developed with the participation and cooperation of multiple groups. Physicians and operations staff are on the committee, and ACCESS has sought out community expertise by working with the Great Lakes Addiction Technology Transfer Center and former SBIRT grantees to learn from their experience. Our evaluator is an expert in substance abuse and a professor at the University of Chicago. Focus groups that have been conducted in the development stage have been critical to addressing the particular demands of practicing medicine in medically underserved neighborhoods. The curriculum/training is interactive and participatory. A balance of academic didactic, small and large group discussions and hands on experience/practice has been incorporated into the teaching and module development.

Unique curriculum development of SBIRT at ACCESS is geared towards the use of SBIRT in a community health setting. It is being disseminated to several different residency programs at different institutions within the Chicago area and therefore, the curriculum is adaptable to multiple types of residency programs and formats. Even with this unique program flexibility incorporated into the curriculum model, an important component is the teaching of SBIRT within the context of addiction medicine and primary care medicine. We are using SAMHSA/CSAT Treatment Protocols as the evidenced based practice for this program. The curriculum is being developed using components from TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians which details screening protocols, brief interventions and referral for treatment guidelines for primary care clinicians. The curriculum is also utilizing information from TIP 34: Brief Interventions and Brief Therapies for Substance Abuse, as a resource for in depth discussions of interventions and therapies. Additional resources from various sources are being integrated into the materials. 

Screening Tools used in SBIRT at ACCESS will use a 2 question brief screen to determine whether further screening, intervention or assessment is required. The curriculum will teach how to use and interpret a variety of tools that can then be used by either the physician or another member of the medical team. These include: CAGE-AID; ASSIST; and AUDIT. These are appropriate for the patient population served by ACCESS. The CAGE-AID and AUDIT have been extensively tested in primary care settings and proven to be useful tools for identifying substance abuse problems.

In addition the following screening tools will be available for use with specific populations: TWEAK; MAST-G; CRAFFT; DAST. 

Unique teaching methods at ACCESS includes looking into the appropriateness and feasibility of using on-line training as well as other methodologies. We will be using standardized cases throughout the training. 

Approaches to training on Brief Intervention, Brief Therapy and Referral to Treatment at ACCESS includes incorporating the **FRAMES** model for brief intervention. (**F**eedback to the patient about personal risk or impairment, **R**esponsibility for change is placed on the participant, **A**dvice to change is given by the clinician, **M**enu of alternative self-help or treatment options are given, **E**mpathic style is used, **S**elf-efficacy or optimistic empowerment is engendered in the patient). Participants will also be introduced to the five components for an intervention: 

a. Introducing the issues in the context of the patients health;b. Screening, evaluating and assessing; c. Providing feedback; d. Talking about change and setting goals; and e. Summarizing and reaching closure. 

Critical to the learning process is the incorporation of the American Society of Addiction Medicine (ASAM) guidelines for treatment as part of the curriculum. Motivational interviewing and stages of change will be taught as the tools for brief intervention and patient communication. Finally, we are developing a specific user friendly referral resource booklet focusing on a variety of services available to patients in their neighborhood or surrounding areas. 

**Service Features**

Unique specialties or patient groups targeted for attention in SBIRT at ACCESS will be a curriculum that is adaptable for multiple residency programs. However, the primary focus will remain on the use of SBIRT in a community health setting working in medically underserved communities. 

Evaluation focus of ***SBIRT at ACCESS*** is to develop and implement a training program that will teach medical residents who are working in community health settings in medically underserved communities with the skills to provide evidence-based screening, brief intervention, brief treatment and referral to specialty care. In addition, ***SBIRT at ACCESS*** will provide a replicable model and curriculum for SBIRT that can be implemented at other medical residency programs and institutions across the Chicago region and beyond. There are two overarching goals of SBIRT at ACCESS 

1. To provide a systematic way to train physicians and other health professionals on the impact of substance abuse on health and to attune them to the possibility of substance abuse in their patients.

2. To provide patients who may be high risk or addicted to alcohol or another drug with a medical home where they can be supported in treatment by their physician.

Therefore, within this context, there will be both an evaluation of the process of implementing SBIRT at ACCESS over time, as well as the outcomes of the training on resident behavior and patient outcomes. A cost/benefit analysis will also be conducted.

**Process Questions**

1. How closely did implementation of the curriculum match the plan?2. What types of deviation from the plan occurred? 3. What led to the deviations?4. What effect did the deviations have on the planned curriculum and performance assessment?

**Outcome Questions**

1. What was the effect (e.g., change in knowledge, attitude, behavior) of the curriculum on participants competencies in the areas covered by the curriculum (understanding of medical conditions associated with substance abuse, screening tools, brief intervention procedures, etc.) ?2. What program/contextual factors were associated with outcomes?3. What individual factors were associated with the outcomes?4. How durable were the effects?5. What were the outcomes of the program for patients seen by the medical residents?

Intentions to expand efforts outside original scope include the intention to integrate SBIRT into the ACCESS network as a standard best practice and quality procedure for all physicians and providers. So ACCESS is collaborating with the Great Lakes ATTC and the Illinois Society of Addiction Medicine on this project as well as with the numerous residency programs that work with ACCESS health centers. We also intend to disseminate information about this program to the Illinois Department of Alcoholism and Substance Abuse (DASA) as well as other partner agencies that ACCESS regularly collaborates with such as the University of Illinois Chicago, TASC, Gateway Foundation, etc. The final outcome of the project is to put SBIRT curriculum in place at ACCESS or other participating medical residency programs. In year 2 and 3 we will be exploring web based training for medical residents 

**Contact Information:**

ACCESS Community Health Network1501 S. California Ave.Chicago, IL. 60608

Project Director: Dr. Abdel FahmyProject Director SBIRT at ACCESSMedical Director of Substance Abuse for ACCESSAustin Family Health Center5835 West North Ave.Chicago, IL. 60639Phone: 773-745-1200Fax: 773-745-3460Email: faha@accesscommunityhealth.net

Project manager: Billie Alexander AveryManager of Substance Abuse Treatment ProgramsACCESS1501 S. California Ave.Chicago, IL. 60608Phone: 773-257-2692Fax: 773-257-6045Email: billie.avery@accesscommunityhealth.net

Project Evaluator: Dr. Harold PollackUniversity of ChicagoSchool of Social Service Administration969 East 60th StreetChicago, Illinois 60637Phone: 773-702-4414Fax: 773-702-0874Email: haroldp@uchicago.edu