1. Integrating Alcohol Screening and Brief in Aboriginal Community Controlled Health Services (ACCHSs) in NSW. National Drug and Alcohol Research Centre, UNSW Anton Clifford Anthony Shakeshaft Catherine Deans Enhancing the management of alcohol-related problems among Indigenous Australians Dennis Gray Steve Allsop Sherry Saggers Edward Wilkes Coralie Ober

2. Funding & other collaborators Department of Health & Ageing NHMRC Indigenous Post-doctoral Research Fellowship (AC) Aboriginal Community Controlled Health Services Armajun AHS; Condobolin AMS; Griffith AMS; South Coast AMS; Yoorana Gunya Family Violence Healing Centre, Aboriginal Corporation Training Prof. Ian Webster; Prof Robert Batey; Dr Rod McQueen; Ms Lynette Bullen; Ms Jayne Schofield; Ms Coralie Ober & Mr Robert Assan, IRIS Team, QLD Health Support Dr. Jim Lemon & Ms. Bianca Calabria, NDARC Acknowledgements

3. Alcohol Screening and Brief Intervention Screening Assessment of alcohol consumption using a valid screening tool Proactive approach Brief Intervention Brief structured advice (5 -20min), motivational interviewing, counselling to reduce harmful alcohol use Used to treat non-dependent drinkers, or to engage dependent drinkers Cost-effective for reducing harmful alcohol use (Kaner et al. 2007) Multiple factors influence its routine uptake in primary health care

4. Project Aims 1.Implement evidence-based Alcohol Screening and Brief Intervention in Indigenous Community Controlled Health Care 2.Examine the level of tailoring required for its integration and ongoing use in routine care

5. Settings Armajun AHS, Inverell Condobolin AMS Griffith AMS Yoorana Gunya Family Violence Healing Centre South Coast AMS

6. Service Characteristics Indigenous (>15yrs old) clinic presentations (2007-2008) Clinical team AOD team SEWB* team Legal team PIR System Number of health staff South Coast 3387- Ferret Medical Director 24 Griffith 493 -- Ferret Medical Director 10 Condobolin1346-- Medical Director 4 Armajun 328 --- Medical Director 3 Yoorana Gunya 135 (Agency Referral only) ---7 *SEWB: Social and Emotional Well-being

7. Stages and methods Stages 1. Alcohol SBI practices and perceptions of healthcare providers (n=48) 2. Develop and implement intervention to enhance alcohol SBI 3. Evaluate the impact of the intervention Methods Semi-structured focus group and individual interviews Ethnographic field notes Clinical audit

8. Results: practices Method and rates of recording Alcohol SBI Condobolin (n=130) Griffith (n=101) South Coast (n=200) Armajun (n=54) Recorded Alcohol Information (%) 14422519 Medical Director (Electronic records) Screening (%) 1013210 Intervention (%) 9510 Paper Records Screening (%) 03154 Intervention (%) 1080 Health Assessments Adult Health Check (%) 426612

9. Key Factors Influencing Alcohol SBI 1.Outcome Expectancy “If someone comes in for a cough and we automatically start asking them about drugs and alcohol, they’re going to turn around and go back out the door.” (RN) 2. Role Congruence “I do health checks, and that’s (alcohol) one of the mandatory components, so every time anyone has a health check I ask. But I wouldn’t really outside of that.” (AHW) 3.Use of existing clinical systems and processes “I know about the alcohol questions in MD, but I must admit I tend not to use them. That doesn’t mean I don’t know which of my patients drink too much.” (GP) 4.Options for alcohol referral Results: perceptions and practices

10. Training and resources Local experts Practical based Outreach support Integrate alcohol SBI into existing systems and processes Reinforcement contact Audit and Feedback Feedback of alcohol SBI activity Social Networking Link in with local D & A services Intervention

11. Case example: Intervention Implementation Substance Misuse Service Education & training of team leaders in Alcohol Treatment Guidelines Supported team leaders to: - identify simple, valid alcohol screener (AUDIT-C) -Implement AUDIT-C across all teams -Integrate AUDIT-C into client assessment forms and Ferret Trained healthcare providers in evidence-base alcohol SBI (AUDIT-C and Feedback, Listen, Advice, Goals, and Strategies) Audit and feedback and ongoing support for reinforcement

12. Integration of AUDIT-C

13. AUDIT-C Scoring Correct scores

14. risky/high risk drinkers offered intervention Integration of Intervention

15. Intervention type by drinking risk drinkers offered intervention type

16. Intervention type by readiness to change

17. Next Stage: Measure the effect of the intervention on rates of alcohol SBI across all services Measure the effect of the intervention on rates of alcohol SBI across all services My contact details: Anton Clifford a.clifford@unsw.edu.au 02 9385 0386

18. Distribution of Indigenous-specific alcohol research, 2000-2007 (N=119 studies), (Shakeshaft, Clifford et al, in press) Research response to the burden of harm

19. ContextProcessType Health Assessments ATSI Health Check New patient intake Care plans Standardised, not evidence- based* Alcohol-related presentations Triage, Standard consultations Informal, not evidence- based** All presentations No reports of routine delivery Type and context of SBI: pre-intervention *One ACCHS reported using evidenced based questions from Medical Director as part of their Health Assessments ** One GP reported using the CAGE instrument, a validated alcohol screening tool

20. Background Indigenous Australians experience a high burden of alcohol-related harm e.g. Indigenous alcohol-related hospital admissions in NSW 2 to 4 x non- Indigenous rates Lack of formal evaluations of: - alcohol interventions to reduce this harm (Gray et al. 2000) - implementing evidence-based alcohol interventions in Indigenous primary health care (Shakeshaft et al. 2009 [In press])

22. Case example: Intervention Implementation South Coast AMS, Substance Misuse Service 317 alcohol assessments of 209 clients after introduction of AUDIT-C one assessment (146 clients); two (31 clients); three (23 clients); four (7 clients); five (1 clients); six (1 client)

24. Case Example: practices AODMental Health Quit Smoking Alcohol ScreeningYesNo When Intake-- Screening questions Drinks/day Clients self-classify -- Intervention Not documented-- Primary method of recording Paper