1. University of Texas Health Science Center at San Antonio ®

2. Project S-START Project Aim: To improve knowledge, attitudes and SBIRT practices of South Texas resident physicians in six medical specialties, with sustained curricular use and clinical practices

3. Project S-START Key Personnel: Project Director: Janet F. Williams, M.D. – Dept Pediatrics Project Co-Director: Sandra Burge, Ph.D. – Dept Family Medicine Project Coordinator: Suyen Schneegans, M.A. - Dept Pediatrics Director of Evaluation: Nancy Amodei, Ph.D. – Dept Pediatrics Key Policy Organizations: Medical School Dean & Former Dean/Current UTHSCSA President Graduate Medical Education Deans Council of Residency SBIRT Trainers (CRST): Pediatrics (UTHSC; BAMC military) OB-Gyn Family Medicine (UTHSC; South TX, Fort Hood, Santa Rosa) Psychiatry (Adult & Child) Internal Medicine (UTHSC; South TX) Surgery

4. Program Structure & Start-up Resources for all Departments Thea Lyssy, Website & Curriculum Developer Pediatrics Janet F. Williams Noemi Adame Lizette Gomez Sylvia Leal-Castenon Juan Parra FCM - UT Sandra Burge Nida Emko Alexandra Loffredo Manuel Oscos-Sanchez Internal Medicine Patricia Wathen George Crawford Michelle Conde Sean Garcia OB-GYN Erin Nelso n Gabriel Medrano Elly Xenakis Psychiatry Michael Dawes Brenda Talley Vivek Singh Jason Schillerstrom Internal Medicine (S. TX) Gary Souffrant James Hanley Rosita Frazier Surgery Daniel Dent Ronald Stewart Ross Willis Shannon Lopez Rochelle Cortes FM – Fort Hood Doug Maurer Drew Baird Dena George Zaal Paymaster FM – Santa Rosa Tamara Armstrong FM- McAllen James Tysinger Sunand Kallumadanda YR 01 YR 02 YR 03 Adolescent Medicine (BAMC) Elisabeth Stafford Dale Ahrendt Jesse Barondeau

5. Site Locations Family Medicine – Fort Hood UTHSC- SA Brooke Army Medical Center (BAMC) CHRISTUS Santa Rosa Family Medicine – McAllen Internal Medicine – (RAHC) Regional Academic Health Center

6. Program Model No further questions 1) Ask pre-screening questions Begin Screening Low to Moderate Risk Moderate to High Risk High to Very High Risk Brief Intervention Brief Intervention & Referral to Treatment Referral to Treatment If “negative” If “positive ” Evidence-based algorithm is tailored to each department Goal: sustainability & to find ways to reinforce it in the program and the resident’s practice Praise

7. Faculty Training Used the Train the Trainer model to train SBIRT faculty in: Pediatrics Family & Community Medicine - UTHSCSA Family Medicine – Fort Hood Family Medicine – CHRISTUS Santa Rosa Other Methods: Personal consultation CRIT (IM Chief Resident Immersion Training in SBIRT) Sharing resources via project website Council of Residency SBIRT Trainers (CRST) Newsletter Email correspondence

8. Length of the training program: Training is longitudinal, infused through the length of each training program - 3 to 5 years 8 proposed training modules: 1. Cultural Competency approaches to SBIRT services 2. Medical Conditions linked to Substance Abuse 3. Use of Pre-Assessment & Screening Tools 4. Brief Interventions & Referrals to Treatment procedures 5. Pharmacotherapy for relapse prevention, maintenance, & other prescribing drugs 6. Outpatient Medical Management & Integrated Provider System 7. Electronic Medical Health Records 8. Administrative Issues Curriculum Description – page 1

9. Curriculum Description – page 2 Screening tools used in the curriculum: CRAFFT, CAGE, CAGE-AID, TACE, ASSIST, BNI-ART Brief Intervention (BI) procedures: BI spectrum of skills: positive feedback, build strengths, dispel myths, brief directed advice, range of intervention strategies from brief to multisession discussions. Motivational interviewing/ Motivational enhancement techniques Referral to Treatment (RT) Support Online Bexar County Substance Abuse Resources Directory SAMHSA Treatment Locator Resources Mid-Coast Family Services (regional referral service)

10. Methods of Curriculum Delivery Training workshops Lecture/discussion Objective-driven learning modules/discussion Grand Rounds Video library Project S-START Website Revised Medical Record templates Pocket Card Assignments Pocket Card Reminders Self-directed/monitored online learning (Blackboard modules) OSCE (Observed Standardized Clinical Exams)

11. SBIRT Curricular Strategies by Specialty PediatricsOB- GYN PsychiatryInternal Medicine IM - ERAHC FCMFM – McAllen FM -Fort Hood FM -Santa Rosa Surgery Large Group Didactic Lecture + ++ + + +++ + Small Group Discussion + + + + ++ + Skill-Building Workshops ++++ Reading Assignments ++ + + Screening Questions In Medical Records +++ + +++++ + ( likely but not in place yet) Reminder Pocket Cards + ++ + Screening Assignments* + + + Inpatient Clinical Supervision + + + + + + Outpatient Clinical Supervision + ++ (child psych only) ++ + + ++ Independent Study Module (Blackboard) + + + + OSCE (Observed Standardized Clinical Exams) + +

12. Dissemination Model – page 1 Posters AMERSA, 2009 Society for Adolescent Medicine, 2010 6 th Annual Innovations in Health Science Education, 2010 Annual Research Day at Fort Hood, 2010 Pediatrics Research Day, 2010 American Academy of Family Physicians, 2010 Texas Academy of Family Physicians, 2010 AAMC/ CDC Public Health in Medical Education Conference, 2010 AMERSA, 2010 (2) North American Primary Care Research Group, 2010 Society for Adolescent Health and Medicine, 2011 Innovations in Health Science Education, 2011 (2) AMERSA, 2011 (2)

13. Dissemination Model – page 2 Oral Presentations AMERSA, 2009 (2) Society of Teachers of Family Medicine (45 min x 2), 2010 World Organization of Family Doctors, 2010 American Academy of Addiction Psychiatry, 2010 Southern Society of Pediatric Research, 2011 Society of Teachers of Family Medicine, 2011 Society for Adolescent Health & Medicine (workshop), 2011 Pediatric Academic Societies (workshop), 2011 INebria conference, (workshop), 2011 AMERSA (workshop), 2011

14. Dissemination Model – page 3 Invited Presentations Texas Medical Association, 2009 (3) Texas Pediatric Society, 2009 ONDCP US-Mexico Binational Drug Demand Reduction Policy Meeting, 2010 Society for Pediatric Anesthesiology (keynote), 2010 Pediatrics for the Practitioner, 2010 Northside Independent School District, 2010 Editorial Journal of Adolescent Health, March 2011 issue Social Media Blog on ONDCP website, 2010

15. Dissemination: CRST Meetings Council of Residency SBIRT Trainers (CRST) Meetings Date PediatricsBAMCFCMInternal Medicine PsychiatryOB-GynFM – Fort Hood FM – Santa Rosa TraumaNursing 1.29.09211-21--1- 1.30.092-22------ 9.29.0942122---3- 12.08.09512111---1 3.09.10711-1-11-1 8.17.10422211---- 2.15.115-21----1- 6.28.112-2--1---- 7.19.115-211---3-

16. Dissemination: Newsletters CRSTy Times Newsletter 6 Editions July 2009 September 2009 January 2010 July 2010 December 2010 July 2011 Resident Newsletter Will be sent out quarterly Will serve as a reinforcement for SBIRT and evaluation reminder

17. Dissemination: Project Website Project S-START website http://familymed.uthscsa.edu/sstart/ Total number of hits & views Timeframe: 1.06.09 to 7.31.11 Total # of hits = 28,510 Avg. hits per day = 30 Total page views = 10,089 Avg. page view per day = 10

18. Dissemination: Substance Abuse Resource Directory Bexar County Substance Abuse Resource Directory http://bexarlist.com

19. Dissemination: Publication Committee Writing Group Meetings – work on SBIRT publications Have had 3 meetings Submissions to the Substance Abuse journal 1. Lessons from the field: Challenges in implementing cross- disciplinary SBIRT residency training curricula 2. Opportunities and challenges: Implementing a brief assessment and a brief intervention in substance abuse consults in the South Texas veteran’s health care system 3. Implementing adolescent SBIRT education in pediatric residency curricula

20. Sustainability Model: Electronic Health Record Example of EHR changes – UTHSC FCM Alcohol Other drugs Tobacco * Screenshot from Sunrise

21. Sustainability Model: Medical Health Records Acute Care Encounter Example of Paper HR change – Pediatrics Alcohol Other drugs Tobacco New Pediatric iPad Project: All residents SBIRT Algorithm & Pocket Cards

22. Sustainability Model: MHR in Pediatrics Child Health Record (11-20 years-old)

23. Sustainability Model: State SBIRT Project Proposed 5 year SAMHSA-CSAT grant: Texas SBIRT Project Collaborated with the Texas Department of State Health Services (DSHS) DSHS will develop an integrated model of care to provide SBIRT within primary care settings UTHSCSA will serve as a centralized web-based clearinghouse to: disseminate SBIRT related information link people with SBIRT tools and resources pair new providers with an experienced mentor develop an SBIRT mobile application find speakers to promote SBIRT provide training at professional conferences and meetings