**University of California, San Francisco**

**An SBIRT Medical Residency Program at San Francisco General Hospital**

**Program Description**

The overall purpose of this program is to establish an SBIRT curriculum for resident physicians at San Francisco General Hospital (SFGH). SFGH is the primary provider of safety-net health care in the City and County of San Francisco. Serving some 100,000 people a year, the patient population is 29% Hispanic; 25% White; 21% African American and 20% Asian; 80% receives either publicly-funded health insurance or is uninsured, and 8% are homeless. The population served by SFGH is disproportionately affected by HIV/AIDS, advanced disease, endemic violence, mental illness, and alcohol and drug disorders. 

Our program's training goals are to: (1) teach 195 primary care residents skills to provide evidence-based Screening, Brief Intervention, Referral and Treatment (SBIRT) for patients with or at risk of substance use disorders; (2) integrate SBIRT into the core curriculum of residency programs on a long-term basis; and (3) activate a system of services that links SBIRT with specialized treatment programs in medical and social service settings. Our dissemination goals are to: (1) identify "early adopters" of innovation; (2) develop a cross-departmental strategy to offer training to all SFGH residents; and (3) disseminate curriculum and program models to local and regional physician and non-physician training programs and statewide medical communities and agencies. 

**Program Model**

Our approach starts with a focus on early adopters of new technologies. We have identified early adopters as those resident physicians who elect to work with the county's most vulnerable populations by participating in the UCSF Primary Care Internal Medicine Residency Program at SFGH and the Health Equities Area of Distinction. These physicians have demonstrated an ongoing intellectual interest in and clinical commitment to caring for urban poor patients along the full spectrum of risky, problematic substance use, abuse and addiction. While many SFGH residents will be exposed to SBIRT principles and practice, our most intensive curriculum has been developed for early adopters at both the resident and faculty levels. 

The SBIRT curriculum utilizes knowledge-based didactics, interactive skills building, attitude-shaping small group discussions, and experiential field visits. We introduce a menu of evidence-based screening tools, including the NIAAA single question screener for alcohol, AUDIT/AUDIT-C, and the ASSIST for other drugs. Brief intervention skills are grounded in motivational interviewing, a directive, client centered counseling style for eliciting behavior change by helping patients explore and resolve ambivalence. 

Program participants include not only resident physicians, but also non-physicians and faculty physicians who serve as Master and Faculty trainers. In a step-wise fashion, Master trainers train SBIRT Faculty, who will in turn train the residents. Institutional SBIRT certification is being sought for faculty and chief residents who participate in the program's faculty development coursework, as these educators play critical roles in the training program's sustainability and expansion to other departments. 

**Service Features**

Successful implementation of the full scale of our training program requires adoption of evidence-based SBIRT services at a systems level. To that end, we collaborate closely with hospital and clinic administrators and staff, who play key roles in establishing policies and procedures for SBIRT best practices in the general medical settings where residents train. In addition, we have established linkages to the system of substance treatment services within the San Francisco Department of Public Health (SFDPH) to teach residents and clinic staff how to make effective referrals. These services include: drop-in centers, detoxification programs, rehabilitation and relapse prevention programs, as well as office-based treatments. We also have collaborations with other programs and partners within, across, and outside of our department and institution. The latter include the California Society of Addiction Medicine (CSAM), the Association for Medical Education and Research in Substance Abuse (AMERSA), the Chief Resident Immersion Training program at Boston University, the Society of General Internal Medicine (SGIM), the American Academy on Communication in Healthcare (AACH), and the San Francisco AIDS Education and Training Center (AETC). 

Program evaluation includes process and outcome measures. Outcome questions focus on the effects of the curriculum on trainees competencies, programmatic and individual factors associated with these effects, and durability of effects. Factors predictive of SBIRT behavior are measured in residents at baseline and biannually after completion of the curriculum. Annual waiting room surveys are designed to rapidly and anonymously assess substance use prevalence and exposure to SBIRT services among patients. Our mission at SFGH is to teach physicians how best to improve the health outcomes of poor, disenfranchised, and vulnerable populations. With a high-impact focus on a whole hospital system rather than a single department, the SBIRT initiative will allow us to train resident physicians in multiple fields serving the same culturally diverse patient population and to develop curricular formats that are tailored to each specialty training program. The successful achievement of our training and dissemination goals will translate into not only improved resident education, but also wider SBIRT practice and meaningful clinical outcomes for our patients. 

**Contact Info**

University of California, San Francisco1001 Potrero AvenueSan Francisco, CA 94110 

Project DirectorPaula J. Lum, M.D., M.P.H.995 Potrero Avenue, Building 80, Ward 84San Francisco, CA 94110Telephone: (415) 476-4082 ext. 411Fax: (415) 476-6953E-mail: plum@php.ucsf.edu 

EvaluatorJennifer E. Hettema, Ph.D.2821 N. Parham Rd., Suite 203Richmond, VA 23294Telephone: (804) 527-4268Fax: (804) 527-4215E-mail: jhettema@virginia.edu