Module 4 Referral to Treatment and Follow-up

Module 4 Referral to Treatment and Follow-up

Presenters & Acknowledgements PRESENTERS Text: TBD Subtext: TBD ACKNOWLEDGEMENTS This module is based on materials from the Adolescent SBIRT Learner’s Guide developed by NORC at the University of Chicago with funding from the Conrad N. Hilton Foundation. Text: TBD Subtext

Learning Objectives 1. 2. 3. 4. Learn which substance use disorder treatment options are best suited to address the needs of adolescents. Understand unique challenges that you will encounter when referring adolescents to treatment, relating to confidentiality and push back. Recognize what constitutes a warm hand-off when referring adolescents to treatment. Understand the importance of follow-up and learn what to cover during these encounters.

Suggested Readings National Institute on Drug Abuse. Principles of Adolescent Substance Use Disorder Treatment: A Research-based Guide. Bethesda, MD: NIDA; 2014. Williams RJ, Chang SY. A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice. 2000;7(2):138-166. Meyers K, Cacciola J, Ward S, Kaynak O, Woodworth A. Paving the Way to Change: Advancing quality interventions for adolescents who use, abuse or are dependent upon alcohol and other drugs. Philadelphia, PA: Treatment Research Institute; 2014. Winters KC, Tanner-Smith EE, Bresani E, Meyers K.

When to Refer Adolescents to Substance Use Treatment A very small number of adolescents will require a level or intensity of treatment beyond that of which you may be able to provide. Specialty substance abuse treatment may be necessary. In 2013, 1.3 million youth age 12-17 were in need of treatment, but only 122,000 (9.1%) received it at a specialty facility. Adolescents must agree to participating in treatment. How you broach and discuss referral contributes to the likelihood of successful treatment. In contrast to adults, adolescents are less likely to feel that they need help or seek treatment on

Number of Adolescents Admitted to Substance Abuse Treatment This chart grouped the number of admittances by referral sources, according to the 2008 Treatment Episodes Data Set (TEDS) analysis majority are being referred through the juvenile justice system. many more who are being missed. Through SBIRT, adolescents in need of treatment can be identified and given

When Working with Adolescents Adolescents have a harder time recognizing their own behavior patterns than adults. Young Shorter histories of substance use Unlikely adverse consequences of use Less incentive to change or begin treatment. Depending on the age of the adolescent, the degree of acute risk, and state regulations regarding access to health care by a minor, it may be necessary to involve the parents/guardians of the adolescent regardless of whether the adolescent consents. Breaking confidentiality in this situation can be challenging. Be familiar with legal issues associated with maintaining and breaking confidentiality. Resistance and denial (lack of insight) are characteristic of substance use disorders at this stage of the disease, therefore the adolescent and/or family may be unwilling to

Benefits of Early Referral to Treatment NIDA indicates that adolescents can benefit from substance abuse interventions, regardless of their level of use since any amount of substance use is concerning. Substance use is associated with increased risk of motor vehicle accidents, other injuries, and unwanted pregnancy and contraction of sexually transmitted diseases (STDs) as a result of sexual risk taking, all of which can be a consequence of first time use. Adolescent use is also associated with increased risk of chronic disease, poor school performance, depression, suicide and future dependence. Referrals or “handoffs” for any additional treatment can be challenging, particularly, when working with individuals with substance use problems, however, handoffs are extremely important According to a 2004 Treatment Episode Data Set (TEDS) analysis of adult populations (age 18 and older), only 16% of clients discharged from detoxification programs start a new

Eight Principles To Help with Handoffs Between Levels Of Care11 1. Commitment 2. Responsibility 3. Understanding the client 4. Designation and clearly defined roles 5. Presence 6. Common language for handoffs 7. Practice 8. Monitoring, evaluation and improvement

Commitment & Responsibility Commitment - The practitioner who makes referrals must believe that handoffs are essential for each patient/client and for the organization as a whole. As a practitioner, you play a critical role in successful handoffs, but this commitment must be felt throughout the entire process. Responsibility - Adolescents do not always follow instructions. Many patients/clients do not follow doctors’ instructions for other types of medical treatment either. However, we do not blame a failed handoff in a relay race on the baton. Noncompliance is the reason we should devote more attention to successful handoffs, not an excuse for failing to do so. It

Understanding the Client and Designation and Clearly Defined Roles Understanding the client - We are not handing off an inanimate object, such as a football or an airplane. We must respect and incorporate both the unique needs and circumstances of patients/clients in managing the referral. Designation and clearly defined roles - For a successful handoff, responsibilities of the individual “giving” the patient/client to the next level of care and the person “receiving” the patient/client are clearly defined. In a smooth handoff, the receiver is fully informed of the patient/client and demonstrates that they have understood what the patient/client has experienced before responsibility can be passed on.

Presence and Common Language for Handoffs Presence – Patients/clients are not “sent” but are “delivered.” They could be viewed in the same way as unaccompanied minors are in the airline industry they need to be “handed off” by one supervising airline employee to another when boarding, making a connection and arriving at the final destination. Common language for handoffs - A common language is crucial to activating any successful handoff process. Organizations in virtually every field have specific, unequivocal, highly clarified language that all “players” understand.

Practice and Monitoring, Evaluation and Improvement Practice - A smooth handoff is standardized, synchronized and practiced over and over again. Every field that performs good handoffs engages in incredible amounts of practice to make them happen. Hand offs can be hard to practice in a setting where they are done infrequently. Monitoring, evaluation and improvement - In sports, team members are constantly graded on how well they are playing their roles, and they retain or lose their spots in the line-up based on performance. Grading also identifies areas where teaching can improve performance. When integrating SBIRT into practice, we need to establish mechanisms for

Other Associated Risky Behaviors Risk factors include individual, family and environment. Violence, physical or emotional abuse, mental illness or drug use in the neighborhood and household can all contribute to an increased likelihood that an adolescent will use substances. The 2013 NSDUH reported that 1.4% of adolescents aged 12 to 17 experienced substance use disorder (SUD) and major a depressive episode. The prevalence rises to 3.2%

Screening for Co-occurring Mental Health and Substance Use Problems Consider screening for Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder, Suicide/Depression, Anxiety and Post-Traumatic Stress Disorder (PTSD). Take into consideration the adolescent’s family environment, known co-occurring disorders, and results from screening for other behavioral health conditions can help you make the most appropriate referral(s). Possible screening tools: HEADSS Psychosocial Interview for Adolescents. http:// www.bcchildrens.ca/Youth-Health-Clinic-site/Documents/headss20assessment20guide1.pdf Patient Health Questionnaire modified for Adolescents (PHQ-A) http://www.uacap.org/uploads/3/2/5/0/3250432/phq-a.pdf Child Measures of Trauma and PTSD http://www.ptsd.va.gov/PTSD/professional/assessment/child/index.asp See table of Anxiety Screening Tools below provided by Massachusetts General Hospital http://www2.massgeneral.org/schoolpsychiatry/screeningtools table.asp

Discussing Treatment Options For adolescents and young adults who score at high risk on the CRAFFT, S2BI, AUDIT or AUDIT-C, or other validated screening tool, you may wish to suggest that they seriously consider more intensive treatment than can be provided in your practice setting. It may be advisable to pursue more intensive treatment when co-occurring problem (e.g. medical condition, ADHD) exist. As you work with adolescents and their families to develop the steps of a plan, options for treatment will probably come up. After gaining permission from the adolescent and/or family to do so, suggest and

Guidelines for Determining Appropriate Intensity and Length of Treatment The American Society of Addiction Medicine ( www.asam.org) suggests these guidelines to determine the appropriate intensity and length of treatment for adolescents with substance abuse problems: 1. 2. 3. 4. 5. 6. Level of intoxication and potential for withdrawal, currently and in the past Presence of other medical conditions, currently and in the past Presence of other emotional, behavioral or cognitive conditions Readiness or motivation to change Risk of relapse or continued drug use Recovery environment (e.g. family, peers, school, legal

Types of Treatment Settings The most common Treatment Settings in which adolescent substance use treatment occurs includes: Outpatient/Intensive Outpatient -- The most commonly offered treatment setting for adolescent drug abuse treatment. It can be highly effective and is traditionally recommended for adolescents with less severe addictions, few additional mental health problems and a supportive living environment. Studies have demonstrated that more severe cases can be treated in outpatient settings as well. Partial Residential -- Suggested for adolescents with more severe substance use disorders who can be safely managed in their home living environment. Adolescents participate in 4-6 hours of treatment per day at least 5 days a week in this setting while still living at home. Residential/Inpatient Treatment -- Offered to adolescents with severe levels of addiction, mental health and medical

Types of Treatment Approaches Research evidence supports the effectiveness of various behavioral-based substance use Treatment Approaches for adolescents. One or more of the options below could form a reasonable action plan. Medication treatment for substances have proven effective with adults but are not approved for adolescents. Most adolescent treatment program use an eclectic treatment approach employing multiple therapeutic models listed below. Behavioral Approaches Family-based Approaches

Behavioral Approaches Behavioral Approaches work to address adolescent drug use by strengthening the adolescent’s motivation to change. Behavioral interventions help adolescents to actively participate in their recovery from alcohol and/or drug abuse and addiction and enhance their ability to resist alcohol and/or drug use. Adolescent Community Reinforcement Approach (A-CRA) Cognitive-Behavioral Therapy (CBT) Contingency Management (CM) Motivational Enhancement Therapy (MET) Twelve-Step Facilitation Therapy (12-Step)

Family-based Approaches Family-based Approaches seek to strengthen family relationships through improving communication and developing family members’ ability to support abstinence from alcohol and/or drugs. Involving the family can be particularly important in adolescent alcohol and/or substance abuse treatment. Brief Strategic Family Therapy (BSFT) Family Behavior Therapy (FBT) Functional Family Therapy (FFT) Multidimentional Family Therapy (MDFT) Multisystemic Therapy (MST)

Addiction Medications Addiction Medications are shown to be effective in treating addiction to opioids, alcohol and nicotine in adults. Some preliminary evidence indicates effectiveness and safety for use with minors. The only FDA approved medication for use with this population in treating opioid addiction is Buprenorphine which is approved for use with 16-65 years olds. Opioid Use Disorders Alcohol Use Disorders Nicotine Use Disorders

Recovery Support Services Recovery Support Services aim to improve quality of life and reinforce progress made in treatment. Assertive Continuing Care (ACC) Mutual Help Groups Peer Recovery Support Services Recovery High Schools Resources to find substance use recovery help for teens and young adults Recovery high school resources: https://www.recoveryschools.org/ Recovery schools for higher education: http://collegiaterecovery.org/programs/ Substance Abuse and Mental Health Services Administration’s Guide to Peer Recovery Support Services: https://store.samhsa.gov/shin/content/SMA09-4454/SMA09-4454.pdf Mutual Support Groups: 12-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) for teens, and non-12-step programs such as SMART Recovery Teen & Youth Support Program age 14-22 (http://www.smartrecovery.org/teens/

Additional Resources National Institute on Drug Abuse. Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide. 2014. http://www.drugabuse.gov/publications/principles -adolescent-substance-use-disorder-treatment-res earch-based-guide/acknowledgements HBO Addiction: Drug Treatment for Adolescents https://www.hbo.com/addiction/treatment/35 trea tment for adolescents.html

Starting the Referral Conversation First set the tone by displaying a non-judgmental demeanor and explain your role and concern. Then connect the adolescent’s screening results, BI conversation, and current visit to the need for specialized treatment. “Stacy, we have talked a bit about your struggles at home, at school, at work, and with your health, and I think some changes around alcohol could help with the issues you identified. Your score of 13 out of 40 on the AUDIT indicates that you might benefit from some help with cutting back on drinking. Working on this through outpatient counseling with a counselor or other health professional like myself could be really helpful. What do you think of this

Referral Conversation Continued Another possible way to start the conversation: “I’m glad that you want to make significant changes in your health by decreasing the amount you drink. You know, adolescents in your situation are often more successful if they also see a counselor who specializes in this topic. We have some excellent programs in our area that have helped many people in exactly your situation. Would you be willing to see one of these counselors to assist you with your plan of recovery?”

Referral Conversation Continued Additional example includes: “Your score of 32 out of 40 on the AUDIT indicates that you are at great risk of developing alcohol dependence. I am very concerned for you and your health. I understand your desire to want to quit drinking on your own and applaud your determination. However, your heavy use of alcohol can be dangerous and you might have problems with alcohol withdrawal too. The best response is to admit you to a residential program that can safely manage your possible withdrawal and help you deal with your alcohol abuse. I would be really worried if you were to just stop

Starting the Conversation Continued Additional example includes: “John, your score on the screen suggests you are at high risk of developing a substance use disorder. We’ve talked about the impact that the use of marijuana has had at school and playing sports, and I think some changes around marijuana could help with the issues you’ve identified. Your score indicates that you might benefit from some help reducing your marijuana use. Working on this with a counselor or a nurse like

Confidentiality Information protected by the Federal confidentiality regulations may always be disclosed after the adolescent signs a consent form. Parental consent must also be obtained in some States. Regulations also permit disclosure without the adolescent’s consent in situations such as medical emergencies, child abuse reports, program evaluations, and communications among staff. Any disclosure made with written client consent must be accompanied by a written statement that the information disclosed is protected by Federal law and that the person receiving the information cannot

Confidentiality Continued When a program that screens, assesses, or treats adolescents asks a school, doctor, or parent to verify information it has obtained from the adolescent, it is making a client-identifying disclosure that the adolescent has sought its services. The Federal regulations generally prohibit this kind of disclosure unless the adolescent consents. Programs may not communicate with the parents of an adolescent unless they get the adolescent’s written consent. The Federal regulations contain an exception permitting a program director to communicate with an adolescent’s parents without her consent when: 1. The adolescent is applying for services. 2. The program director believes that the adolescent, because of an extreme substance use disorder or a medical condition, does not

Confidentiality Continued Other exceptions to the Federal confidentiality rules prohibiting disclosure regarding adolescents seeking or receiving substance use disorder services are: Information that does not reveal the client as having a substance use disorder Information ordered by the court after a hearing Medical emergencies Information regarding crimes on program premises or against program personnel Information shared with an outside agency that provides service Information discussed among people within the program Information disclosed to researchers, auditors, and evaluators with appropriate Institutional Review Board review and approval to ensure the protection of program participants

Effective Treatment Approaches What methods are used to introduce options to initiate treatment is equally important as the timing. Meta-analyses have demonstrated that established treatment options are effective for adolescents, but not enough treatments have been evaluated for a comparative effectiveness study to rank these options.

Effective Treatment Approaches Meta-analyses have found: Brief alcohol interventions lead to significant reductions in drinking and alcohol-related problems for adolescents and young adults, the effects of which listed for up to one year after the intervention. Motivational interviewing has a larger effect on alcohol consumption than other brief interventions for this age groups and has been shown to be effective for adolescents across a variety of substance use behaviors and the effect is retained over time. When brief interventions were individually delivered to adolescents over multiple sessions, they were more effective in reducing the frequency of alcohol and cannabis use, as well as reducing associated criminal behaviors (compared to group and single session brief interventions).

Self-assessment Exercise What are the treatment approaches most frequently used in the environments where students and practitioners work?

Treatment Referral Resources 1. 2. 3. 4. Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Locator: 1-800662-HELP or search www.findtreatment.samhsa.gov The “Find A Physician” feature on the American Society of Addiction Medicine (ASAM): http://community.asam.org/search/default.asp?m bas ic The Patient Referral Program on the American Academy of Addiction Psychiatry: http://www.aaap.org/patient-referral-program The Child and Adolescent Psychiatrist Finder on the American Academy of Child and Adolescent Psychiatry:

Considerations for Referral Process 1. 2. 3. 4. Determining the specific needs of the adolescent to determine the most appropriate referral sources. Evaluating and, whenever possible, removing potential barriers to successful engagement with the helping resource. Explaining to the adolescent in clear and specific language the necessity for and process of referral to increase the likelihood of understanding and follow through with the referral. Arranging referrals to other professionals, agencies, community programs, support groups

Considerations for Determining Needs Determining the specific needs of the adolescent to determine the most appropriate referral sources. Every adolescent is different and has varying needs when obtaining assistance. Consider the many multicultural factors (race, gender, religion/spirituality and primary language spoken, geographical constraints and financial factors, such as insurance coverage and outof-pocket expenses) that impact the treatment process, when making a recommendation. Become acquainted with the available community options for teenagers, including mental health services because specialized drug treatment program may not be available. Identify education and prevention programs for youth in the early stage of substance use. Check SAMHSA’s substance abuse treatment facility locator system (www.samhsa.gov/treatment/index.aspx) or any local directory, as well

Considerations for Referral Process Evaluating and, whenever possible, removing potential barriers to successful engagement with the helping resource. Potential barriers can include: lack of financial resources transportation needs fear that others will find out lack of family support parent/guardian’s lack of access to child care or elder care legal complications; and, medical needs Explain using clear and specific language the necessity for and process of referral to increase the likelihood of understanding and follow through with the referral.

Considerations for Referral Process (continued) Arranging referrals to other professionals, agencies, community programs, support groups or other appropriate resources to meet the adolescent’s needs. Establish working relationships with alcohol and other drug treatment providers in your communities to ensure their adolescents have treatment options that are developmentally appropriate. It is preferable for the referral to be arranged immediately using a “warm hand-off” or “warm transfer” where the addiction professional connects the adolescent directly with the treatment provider by telephone while the adolescent is still in the office. However, if impossible, the practitioner must contact the adolescent within 24 hours to arrange the referral.

Considerations for Referral Process (continued) The speed at which you can link an adolescent to treatment dramatically impacts their likelihood to show up, remain in treatment and experience positive outcomes. Offering a treatment appointment date immediately and reminding the adolescent of their initial scheduled appointment usually improves the rate at which adolescents will begin treatment. The first 24 hours after an adolescent’s initial contact is a critical period in initiating treatment. Research shows that if the gap between your session and first appointment for a different level of care is

Motivation and Referral For adolescents who express little motivation to go into more intensive treatment, the primary task is to engage them in a discussion that allows you to get a good understanding of how they see substance use which explains their decision not to choose treatment. When adolescents hear themselves describe their thoughts and feelings about their substance use to a non-judgmental listener, they are more likely to understand their mixed feelings which serve to increase their level of motivation for treatment. You can facilitate this process by asking open-ended questions, making empathic reflections and using summary statements. The following is ansaying example how drinking these three strategies can “So you’re thatthat youshows know that is bringing be used together: you down and messing up your relationships with your family, but you are just so tired and you feel like ‘what is counseling gonna do for me?’ You think it’s possible that it’s partly the drinking itself that’s got you feeling this way, but you just don’t feel ready to commit to treatment

Motivation and Referral Continued After making reflective listening statements that express an understanding of why the adolescent does not want to go to treatment, move on to the next steps. You might ask what would need to happen to raise their level of motivation. If the initial response is something vague or noncommittal like “I don’t know,” try saying something like: “It’s hard to know what could happen that could make you feel more motivated for counseling. Sometimes people get more motivated because some things in their life get worse, like health problems or getting poor grades in school. Sometimes people get more motivated to go into counseling because something good happens that makes it easier for them, like they find out that they

Motivation and Referral Continued If the adolescent is willing to consider treatment options at this point, move to discussion of barriers to treatment and linkage to treatment. If the adolescent is not willing, you might close the discussion with a summary statement that conveys that the option is open for more intensive treatment in the future. “You’re saying that you know that counseling can help people, and has even been helpful to you, but you just don’t want to go back to it at this time in your life because you don’t feel ready to give up drinking yet. You feel like you’ll know when you’re ready, and you’ll get treatment then. Did I get that

Motivation and Referral Continued For an adolescent who expresses moderate motivation to go into more intensive treatment, the primary task is to express understanding of their ambivalence and elicit change talk that will tip the balance in favor of the adolescent agreeing to treatment. This can be done by exploring ambivalence, expressing empathy and reflecting: “Tell me about some of the reasons why you would be motivated to get counseling.” “Tell me about some of the reasons why you would not be motivated get counseling.” “What would need to be different for you to go to counseling?”

Motivation and Referral Continued Use reflections to express empathy toward their responses. For example: “So, you’re saying that you want to go to treatment because you’re sick of being tired and grouchy. You really sound tired of that life.” “I see the way you light up when you talk about how you’d like to be a better friend.”

Motivation and Referral Continued You will experience more success by accepting the fact that the adolescent is ambivalent and that sometimes they will not feel like acknowledging the potential benefits of treatment. Always remain patient and express empathy. Double-sided reflections that include both sides of the adolescent’s ambivalence show that they “So, what I’m hearing is that you don’t really are understood: feel like getting counseling now because of how much work it is, even though you think it would make things better for you and your family.”

Motivation and Referral Continued Ask questions that invite the adolescent to describe the potential benefits of treatment: “How do you think it would affect your life if you got counseling?” “It sounds like you feel that going to treatment could help your health. Tell me more about what causes you say that.”

Motivation and Referral Continued For adolescents who express high motivation, avoid trying to convince them that they are making a good choice, because such a response could run the risk of raising pushback in someone already motivated. Instead, allow the adolescent to explain their reasons for that motivation: “You indicated quite a bit of motivation to get treatment for your alcohol use right now.” “Tell me some of the main reasons for that. You mentioned some health concerns.” “Is that also related to why you want to get treatment? How so?”

Motivation and Referral Continued Explore possible ambivalence. This is helpful because it allows the adolescent to know it is OK to talk about their reservations. The reason to discuss ambivalence is to decrease the likelihood that these reservations will result in not following through. You might approach discussing ambivalence in a highly motivated client by saying: “You’re describing a lot of reasons why it would be a good idea for you to get counseling for your alcohol dependence. Sometimes even when someone is really motivated to get treatment, they might have some negative feelings or concerns about doing that. How do you feel about it?”

Motivation and Referral Continued Support change talk, expressing recognition and appreciation that the adolescent is committing to do something that: a) is not easy b) is a positive step to improve their life; and c) is taking this step willingly and openly. “I appreciate that you’ve been so open in looking at the ways alcohol has been complicating things for you. Now you’re planning to take back control of your life by going to treatment (or involvement in a support group). That’s a really positive step you’re taking, and I know it’s not easy.”

Barriers to Treatment Surveys conducted by SAMHSA found that “cost” is the most often reported reason for not receiving treatment, among adults and adolescents who felt a need for treatment and made an effort to receive treatment (37%). Among adults, 9% feared that seeking treatment would negatively impact their jobs. When discussing treatment options, make sure to explore insurance coverage, and concerns about costs and take care to discuss resources that are free or have a sliding fee scale. If the adolescent simply is not interested in treatment at this time, rather than push them and jeopardize future opportunities, it is important for you to accept and respect their decision in a non-judgmental manner. They may be more willing to accept the notion of treatment during future sessions or at some later time. A follow up conversation

SAMHSA’s Online Treatment Locator SAMHSA’s online treatment locator is available at http://www.samhsa.gov/treatment and National Help Line 800.662.HELP (4357) and offers confidential, free, 24-hour-a-day, 365-day-a-year, information services in English and Spanish for individuals and family members facing substance abuse and mental health issues. The Help Line service provides free referral to local treatment facilities, support groups and communitybased organizations. If the adolescent has no insurance or is underinsured, provide a referral to the local state office responsible for state-funded treatment programs, as well as offer

Scheduling Treatment Appointments Consider a three-way call involving you, the adolescent, the parents/guardians (as appropriate), and the treatment program or provider immediately after the adolescent consents to treatment. The purpose of the call is to: inform the treatment staff or clinician of the adolescent’s substance use, treatment barriers or ambivalence; agree on whether the program or some other treatment option is best; gain support from the program to solve or remove some of the treatment barriers (e.g., transportation, cost, insurance coverage, child care, evening appointment); and

Scheduling Treatment Appointments Have this call within three days of gaining the adolescent’s consent is best; after that, no show rates climb steeply. After 14 days, about 50% of clients will not show for treatment, regardless of their motivation. Making a referral that adolescents do not reach wastes their time and yours.

Video Resources Boston University’s BNI-ART Institute produced several excellent brief videos that might be helpful to you when discussing referral: Video 1 - insensitively confronting a young adult with an alcohol-related injury Video 2 - an alternate, respectful brief intervention with the same young adult Video 3 - an exceptionally sensitive video of a clinician helping an ambivalent patient/client make his own decisions and plan to get intensive treatment Video 4 – SBIRT for alcohol use with a college student These videos are located at: http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/ SBIRT Oregon produced several other strong examples of SBIRT in practice, including a video entitled “Clinical workflow with behavioral health specialist” which demonstrates a warm handoff. These videos are located at: http://www.sbirtoregon.org/videos.php University of Florida Institute for Child health Policy & Cherokee National Behavioral Health produced a video entitled “The Effective School Counselor With a High Risk Teen: Motivational Interviewing Demonstration.” The video is located at: https://www.youtube.com/watch?v TwVa4utpII

Communicating with Referral Sources It is essential that you and the treatment program or provider be able to share information and share responsibility for helping the adolescent. Use a Release of Information form. Make sure that your release forms comply with your state and federal substance use medical record confidentiality laws and The Health Insurance Portability and Accountability Act (HIPAA).

Application Exercise What treatment options would you recommend to the adolescent? Role-play - Adolescent: You are a 16-year-old adolescent who is worrying all the time about failing in school. You have had several acute feelings of panic and doom, which also worry you a lot. You know that the school has notified your parents that you are on academic probation due to your low performance. Sometimes you just feel like blowing up, the pressure gets so high. You feel you have to work harder than other students your age. If asked about your marijuana use, you might say something like: “I don’t think I need to stop smoking. I only smoke weed a few times a week with my friends. My health is good and besides,

Application Exercise What treatment options would you recommend to the adolescent? Role-play - Adolescent: You are a 20-year-old young adult who seeks some help because you feel like you have very little energy and feel depressed and blue. If asked about alcohol use, you might say something like: “I drink four or five drinks most days after classes and a few more on the weekends. It is really the only way I relax. I have a lot of stress in my life, and it is just my release. I don’t see any problem with it.” AUDIT score of 25 S2BI score of Weekly Use of Alcohol

Let’s Give It a Try! Role-play Exercise: Partner with someone to practice conducting referral. One person will act as the practitioner who has administered the AUDIT. Your partner will act as the adolescent who scored a 17 on the AUDIT and has sought help for stress and depression. Young Adult: You are an 18-year-old adolescent who called with concerns about feelings of stress and depression. You are concerned about poor performance at school. If asked about your alcohol use, you might say something like: “I stopped going out to drink with my friends as much as soon as I started getting D’s at school. Sometimes I will have a beer, never more than two and I don’t do it every night. I heard that beer is okay. It’s not the hard stuff. I don’t smoke. I don’t do drugs. I wouldn’t do anything that would get me in trouble.”

Working with Physicians in Ongoing Care Coordination Adolescents who are identified as having risky alcohol, tobacco and other substance use patterns and/or are in need of mental health services may need to be referred to a physician for additional care. The need for medical services for an adolescent that are identified during the SBIRT protocol could be related to: alcohol-related physical illnesses or impairments; detoxification necessity; psychiatric conditions; and/or pharmacotherapy options.

Maintaining Communication with the Physician It is imperative for you to coordinate these services with the physician, follow-up with the adolescent or young adult to ensure services are being received and share information so that you and the physician are working together (with a signed Release of Information, of course. Below are some tips for you when referring to a physician to ensure that needed care is effective and consistent: Locate a knowledgeable prescriber Send a written report Make it look like a report—and be brief Keep the tone neutral

Locating a Knowledgeable Provider It is not uncommon for an adolescent or young adult to not have a primary physician. Resources you can utilize to help them find one include: The American Academy of Addiction Psychiatry’s (AAAP) physician locator program is located at http://www2.aaap.org/client-referral-program. The American Society of Addiction Medicine’s (ASAM) physician locator system is at http://www.asam.org/. The SAMHSA Locator includes residential treatment centers, outpatient treatment programs and hospital inpatient programs for drug addiction and alcoholism, however it does not list individual physicians, advance practice nurses, psychologists, social workers or other addictions specialists who do not practice within licensed treatment programs. This service is located at: http://findtreatment.samhsa.gov/. SAMHSA also maintains a list of state agencies in the Directory of Single State Agencies (SSA) for Substance Abuse Services http:// www.samhsa.gov/sites/default/files/ssadirectory.pdf. Develop a list of addiction-focused physicians and other specialists in your area who provide specialized behavioral and mental health

Send a Written Report Maintain consistent communication with the adolescent’s physician so any concerns that arise during a session with you can be addressed by the physician (or vice versa). Significant clinical issues encountered or addressed by either you or the physician need to be included in the adolescent’s medical record. When information is in a medical record, it is more likely to be acted on. The most efficient way to update a physician on the status of the adolescent or significant changes potentially impacting care is to submit a written report to the physician’s office. This report can be submitted via fax, mail or email, depending on the communication preferences of the

Make It Look Like A Report and Be Brief Since physicians maintain caseloads of hundreds of clients at a time, it is important that your written report be brief, concise and official. A report should include the date, the adolescent’s name and date of birth, your contact information and any relevant information that needs to be conveyed to the physician so he/she may remain informed of the adolescent’s progress and current status. Update reports should not be longer than one page, anything longer than one page will probably not be read.

Keep the Tone Neutral Provide details about the adolescent’s use or abuse of alcohol, prescription medications or illicit drugs. Avoid making direct recommendations about prescribing medications, as doing so could be practicing beyond the scope of your license/credential. The physician will use their clinical judgment to draw their own conclusions. Providing “just the facts” will enhance your alliance with the adolescent’s physician and make it more likely that he/she will act on your

Follow-Up and Support From your first encounter with the adolescent, discuss that you would like to follow-up with them, regardless of their decisions about continuing to meet with you, cutting down or abstaining from unhealthy drinking or other substance use, or getting additional treatment. Adolescents and adults generally do not know what to expect from counseling or treatment. If follow-up is presented as the standard of care and what you do for all of your adolescents and

Follow-Up and Support Continued Reconnect with the adolescent after a couple of weeks to see if they got what they needed from you, to ask how things are going and to check-in to see if any additional services are needed. Treat relapse as an opportunity to engage in additional or different treatment rather than a failure. There are two overlapping types of follow-ups that are distinguishable mainly by how soon they occur after your session and the amount of information that you collect: Booster and linkage follow-up

Types of Follow-Up Booster and linkage follow-up Controlled research studies have shown that a brief telephone call within a few days or weeks of receiving a brief intervention for unhealthy alcohol use dramatically reduces alcohol intake, unhealthy drinking practices, alcohol-related negative consequences and alcohol-related injury frequency. The booster and linkage follow-up reinforces the action plan made, demonstrates your concern for the adolescent’s health and well-being and gives you both an opportunity to resolve barriers or ambivalence through additional brief intervention. A booster follow-up also gives you an opportunity to re-administer the CRAFFT, S2BI, AUDIT-C, AUDIT or

Types of Follow-Up Continued Recovery management follow-up This type of follow-up generally occurs several months after your last interaction with the adolescent. These are primarily booster and linkage reconnections that give you and the adolescent opportunities to assess whether issues have been resolved, assess need and motivation for additional services and to reinforce changes that have been made since your first contact. They also give you an opportunity to measure change and gather feedback for improving your services.

Making Phone Contact Follow-ups should be brief contacts, generally not more than 15 to 20 minutes and should always utilize Motivational Interviewing techniques. The follow-up may begin with a brief, casual conversation as a way to get reacquainted. The goal of the call and of the practitioner is to help adolescents solve the problems for which they initially contacted you and to link people to supports and services that they may need now before they experience any other problems.

Making Phone Contact The follow-up is also an opportunity to address concerns that were identified during the interaction (e.g., risky alcohol or marijuana use) and to measure change (e.g., reduction in alcohol consumption) since their last contact with you. You can ask some of the same questions (e.g., CRAFFT, S2BI, AUDIT, or AUDIT-C) that the adolescent was asked when they first sought help, so that you both can see what has improved, what still might be troubling them and how you can offer additional services.

Making Phone Contact Continued You could also remind the adolescent that you had told them you planned to follow-up. If you reach the adolescent, you might say: “Hi, [name of adolescent]. This is [your name], and I’m following up on the conversation we had on [date]. This will only take a few minutes. Is this a good time to talk?” If yes, continue; if no: “OK, that’s not a problem. We can schedule an appointment to talk another time. I am available [day, times]. Which time would work best for you?” “You may recall that when we spoke some time ago, I stated that I would try to check back in with you to see how you are doing. Is this OK with you? Do you have any questions?”

Making Phone Contact Continued Confidentiality is an essential element of any outreach to an adolescent. If you call and get voicemail, you might say: “Hello. This message is for [the adolescent’s name]. This is [your name]. I’d like to take a few minutes to speak with you. Please call me at [your work number] between the hours of [time]. If I don’t hear from you, I will try back again on [date].”

Making Phone Contact Continued If client does not agree to a time, you might say: “I understand how hard it is to find a good time. Did you have any questions about why I’m calling? [pause for response] OK, I’ll go ahead and leave my number with you. I look forward to talking with you soon.”

Extracted from CRAFFT Provider Guide Recommendations for Screening at Follow-up Adolescents whose CRAFFT score is 0 or 1 who receive brief advice should be asked about continued substance use at the next health care visit. Those who have continued to use should be re-screened with the CRAFFT. Those who have stopped should be given praise and encouragement. Any adolescent who answers “yes” to the car question and contracts with the practitioner not to drive or ride with an intoxicated driver should be given a follow up visit to ensure they have been successful. Adolescents with a CRAFFT score of 2 or more who receive a brief intervention in the office should be followed to determine whether they have been able to make progress towards the goals defined in the intervention. Adolescents who are referred for substance abuse treatment should be followed to track their progress and keep them connected with their medical home. Providers should ask them what they do in treatment, how it is going, and what is planned

Let’s Give It a Try! Role-play Exercise: With a partner, practice conducting follow-up Your partner will act as the adolescent who scored a 4 on the CRAFFT and was referred to a treatment provider for alcohol and marijuana use, and feelings of anxiety and depression. Adolescent: You are a 16-year-old adolescent, who originally presented with concerns about feelings of anxiety and stress. During the initial visit with the practitioner you screened positive for risky alcohol use and weekly marijuana use. You have been receiving care with a treatment provider for your alcohol and marijuana use as well as your concerns about feelings of nervousness, sadness, and difficulty concentrating in class. If asked about your substance use, you might say something like: “I’ve been going to my appointments. I’ve stopped drinking alcohol. And now I’m only smoking weed after school once in a while. I’ve stopped smoking before school and I don’t smoke anything that would