The CDC Implementation Guide on Alcohol Screening and Brief Intervention: What PHNs Should Know. December 6, 2016 Webinar

Transcription

1 The CDC Implementation Guide on Alcohol Screening and Brief Intervention: What PHNs Should Know December 6, 2016 Webinar

2 Phone and Webinar Etiquette All attendee telephones will be muted If you have a question for the presenter: Type it in the Question Window on the right side of your screen Click on send privately button Questions will be answered at the end of the session in the order in which they are received Please refrain from sending messages to entire audience during the presentation Disclosures The presenters and planners of this educational activity have no conflict of interest and have not received any financial support for any part of the planning of this presentation.

3 Disclosures In order to successfully complete the education activity and receive 1.00 nursing contact hour, webinar APHN members must attend the entire Live presentation and complete the online course evaluation which will be ed to APHN members who were on the Live webinar. Continuing education credit will only be provided to those APHN members who attend the entire educational activity on 12/6/2016 and complete the evaluation form within 30 days following the live presentation. The webinar will be archived and slides will be posted on the members section of the APHN website Accreditation Statement Continuing education credit will be provided through the Public Health Nursing and Professional Development Unit. The Public Health Nursing and Professional Development Unit, North Carolina Division of Public Health, is approved as a provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. 3

4 The Presenters Ann M. Mitchell, PhD, RN, AHN-BC, FIAAN, FAAN Professor, University of Pittsburgh School of Nursing Irene Kane, PhD, MSN, RN, CNAA, EP-C Associate Professor, University of Pittsburgh School of Nursing Diane King, PhD Director and Research Assistant Professor, University of Alaska Anchorage Center for Behavior Health Research & Services; Institute of Social and Economic Research Beth Kelsey, EdD, APRN, WHNP-BC Director of Publications, NPWH Susan Rawlins, MS, APRN, WHNP-BC Director of Education, NPWH

5 Learner Outcomes for Webinar Upon completion of this webinar, PHNs will have increased knowledge regarding how to successfully plan, implement, & evaluate a successful and sustainable Alcohol SBI Program using the process outlined in the CDC Implementation Guide for Alcohol SBI.

6 PHN Core Competencies Addressed Analytic and Assessment Skills Policy Development/Program Planning Skills Communication Skills Leadership and Systems Thinking Skills

7 Implementation Process Basics This presentation is part University of Pittsburgh School of Nursing SBI: Workforce Expansion for Nurse Leaders grant-funded from the Centers for Disease Control & Prevention (CDC) /American Association of Colleges of Nursing (AACN) Grant WIP number: 2014-N-0004 and coordinated with IRETA and the John Hopkins School of Nursing, recipients of CDC/AACN grant. Please also see CDC for comprehensive FASD information.

8 Objectives Educate health professionals on steps to plan, implement, and evaluate an alcohol SBI program Examine step-by-step details on developing and implementing sitespecific programs Emphasize important factors geared towards successful program outcomes Describe important factors that provide sustainability for site-specific program

9 (CDC, 2014) Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use A Step-by-Step Guide for Primary Care Practices

10 Introduction to Alcohol Screen and Brief Intervention: A Critical Clinical Preventive Service Like hypertension or tobacco screening, alcohol screening and brief intervention (alcohol SBI) is a clinical preventive service. It identifies and helps patients who may be drinking too much. It involves: A validated set of screening questions to identify patients drinking problems A short conversation with patients who are drinking too much, and for patients with severe risk, a referral to specialized treatment as warranted. The entire service takes only a few minutes, is inexpensive, and may be reimbursable. (CDC, 2014)

11 Risky drinking affects your patients health. Risky drinking may be associated with: Increasing the risk of hypertension, stroke, type 2 diabetes, cancers Cirrhosis of the liver Injury Violence Increased body weight Can impair short and long-term cognitive function Sexually transmitted diseases Unintended pregnancy Violent crime (CDC, 2014)

12 Implementation Basics I. Laying the Groundwork 1. Familiarize the planning team with alcohol SBI why it is an important medical service and how it works 2. Ensure that practice leaders are committed to implementing alcohol SBI II. Adapting Alcohol SBI to Your Practice 3. Plan Screening procedures 4. Plan brief intervention procedures 5. Establish procedures to refer patients with severe problems III. Implementing Alcohol SBI in Your Practice 6. Train staff for their specific roles 7. Pilot test and refine your plan 8. Manage initial full implementation so it succeeds IV. Refining and Promoting 9. Monitor and improve your alcohol SBI plan over time 10. Publicize your efforts so that others can learn from your experience (CDC, 2014)

13 I. Laying the Groundwork Share the rationale for implementing your new program before making specific changes! (CDC, 2014)

14 Step 1: Understand the Need for Alcohol SBI It is much more than alcohol dependence. The main target population for brief interventions is nondependent, risky drinkers The goal of the brief intervention is to motivate them to cut back or stop drinking. What is risky drinking? How much is too much? See Table at right. (CDC, 2014) A. Risky Drinking Levels for Healthy Adults Any person drinking more than either the daily or weekly levels in the table below is drinking too much. If a person exceeds the weekly levels, a long-term risk for a wide range of chronic conditions can occur. If a person exceeds the single-day levels, he or she risks intoxication, which is associated with a variety of more immediate risks. Healthy men ages All healthy women ages 21 and older Healthy men over age 65 No more than 4 drinks on any single day (5 or more drinks consumed within 2 hours is binge drinking) AND No more than 14 drinks a week No more than 3 drinks on any single day (4 or more drinks consumed within 2 hours is binge drinking) AND No more than 7 drinks a week B. For some people, even less is risky. The levels provided above are just one consideration in defining risky drinking. A variety of health conditions and activities may warrant limiting drinking to even lower levels or not drinking at all. Here are some examples. Individuals taking prescription or over-the-counter medications that may interact with alcohol and cause harmful reactions Individuals suffering from medical conditions that may be worsened by alcohol, e.g., liver disease, hypertriglyceridemia, pancreatitis Individuals who are driving, planning to drive, or participating in other activities requiring skill, coordination, and alertness C. For some people, any drinking at all is risky. Here are some examples. Individuals unable to control the amount they drink. This group includes people dependent on alcohol. Women who are pregnant or might become pregnant Individuals younger than age 21

15 Step 2: Get Organizational Commitment Implementing an effective alcohol SBI plan requires: A firm commitment from the leaders of your practice. Communication of that commitment to all relevant staff. Share CDC Alcohol SBI Fact Sheet with key managers to reach a common understanding of: The need for alcohol SBI in your practice, What alcohol SBI is, Your goals, and How you will inform staff member of your decision to implement alcohol SBI (CDC, 2014)

16 II. Adapting Alcohol SBI to Your Practice It is critical to plan fully all the elements of your alcohol SBI service before you start implementing or training staff to provide it. Step 3: Plan for Screening A complete alcohol SBI screening plan specifies: Which patients you will screen How often you will screen patients Which screening instrument you will use How and where you will screen How you will store and share screening results (CDC, 2014)

17 Who Will be Screened? Ideally, you should screen all of your patients with two possible exceptions: Children under 9 years of age, who are not likely to drink alcohol. Patients who are too ill to answer screening questions at a particular visit. (CDC, 2014)

18 How Often Should Patients be Screened? Because drinking patterns change over time, patients should be screened at least annually. If nearly all of your patients receive preventive-care physical examinations annually, the best time to provide alcohol SBI might be that visit. Alternatively, if many of your patients do not have annual physicals, you might want to screen every patient on the first visit of each year. (CDC, 2014)

19 Which Screening Instrument Will You Use? Recommended Screening Tools: The Single Question Alcohol Screen Single Question Can be included on intake questionnaire Simple, quick, and easy method of screening AUDIT-1-3 (US) Questions 1-3 identify patients who are drinking too much Can be administered in a minute (2-3 minutes for the full AUDIT) (CDC, 2014)

20 How Will the Screening be Performed and Where? Some suggestions are: Via computer before the patients arrives Via questionnaire in the reception room (CDC, 2014)

21 How Will Screening Forms be Scored and the Results be Shared and Stored? 1. Who will score the screening instruments? 2. How will screening results be shared with staff who will provide brief interventions? 3. How will screening results be recorded in the patient s chart? 4. Where will screening forms (if used) be stored and managed? 5. How will patients who screen positive be followed during future visits? If a patient screens positive, you will need to follow up appropriately as you would with any other risk factor. (CDC, 2014)

22 Step 4: Plan for Brief Intervention Two main issues: Who will deliver the interventions? Time Availability Knowledge and Experience Interpersonal Skills Willingness What will the basic elements of your intervention system be? When will interventions be delivered? How will you introduce the intervention for patients who screen positive? What elements will you include in the intervention? How long will interventions typically take? How will you intervene with patients who are likely to be dependent on alcohol? How will you follow patients who receive an intervention? How will the intervention be documented? (CDC, 2014)

23 Who Will Deliver the Interventions? Factors to Consider: Time Availability Knowledge and Experience Interpersonal Skills Willingness (CDC, 2014)

24 What Will the Basic Elements of Your Intervention System Be? Questions to Consider: When will interventions be delivered? How will you introduce the intervention for patients who screen positive? What elements will you include in the intervention? How long will interventions typically take? How will you intervene with patients who are likely to be dependent on alcohol? How will you follow patients who receive an intervention? How will the intervention be documented? (CDC, 2014)

25 Step 5: Establish Referral Procedures Three Available Resources: 1. The Substance Abuse and Mental Health Services Administration (SAMHSA.gov) 2. Your practice s contacts 3. Alcoholics Anonymous (AA) (CDC, 2014)

26 III. Implementing Alcohol SBI in Your Practice The steps for implementation include: Orienting and training all staff Planning and evaluating a pilot test Managing start up of full implementation (CDC, 2014) Picture via:

27 Step 6: Orientation and Training Steps to orientation and training include: 1. Determine who needs training 2. Orient all staff about risky alcohol use and alcohol SBI 3. Help staff become more comfortable discussing alcohol use 4. Train for alcohol SBI specialized functions (CDC, 2014) Picture via:

28 Step 7: Plan a Pilot Test Pilot Testing Evaluation Points: 1. Number of patients in target population 2. Percentage screened 3. Number and percentage who screen positive 4. Percentage of positives receiving an intervention 5. Percentage referred to treatment (CDC, 2014) Picture via:

29 Step 8: Support a Strong Start-Up When starting up your official and permanent program, consider the following: 1. Communicate 2. Provide hands-on help 3. Address unforeseen issues quickly 4. Offer feedback, encouragement, and thanks (CDC, 2014) Picture via:

30 IV. Refining and Promoting Monitor your quality improvement Stay current with developments in other programs Publicize your achievements. (CDC, 2014) Picture via:

31 Step 9: Monitor and Update Your Plan Seek front-line feedback Set specific time intervals to evaluate your program Keep up on research Learn from others (CDC, 2014) Picture via:

32 Step 10: Share Your Success Who to share your success with: Your organization s leaders Local community leaders, organizations, and citizens Members of regional and national organizations committed to quality medical services and advancing alcohol SBI Picture Via: (CDC, 2014)

33 References Centers for Disease Control and Prevention. Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, 2014.

34 Implementing Alcohol Screening and Brief Intervention (SBI) with Alaska Section of Public Health Nursing Supported by: CDC Cooperative Agreement #U84DD

35 Why Should Public Health Nurses Implement Alcohol SBI? Public Health Nurses are in an ideal position to reach/identify patients who drink at risky levels and provide brief education or intervention. Alcohol SBI Fits with public health objectives to reduce health risk through population-based approaches. Alcohol use contributes to increased STD rates, domestic violence, unplanned pregnancies, and FASDs, as well as higher risk for chronic conditions (hypertension, cancer). Risky use can be identified in 1-3 screening questions. 5 minutes of provider-focused counseling has been proven to reduce patients alcohol use over sustained periods.

36 Adoption of evidence based interventions requires systems-level changes, which in turn require planning and commitment of resources The literature has identified two essential ingredients to implementing practice change: Healthcare systems/providers willing to adapt their processes Researchers willing to adapt EBIs so they are feasible yet still effective

37 CDC-funded Opportunity: Project Goals Partner with a multi-clinic healthcare system that provides primary care services, to implement and evaluate alcohol SBI 1. Incorporate SBI into day-to-day clinical care 2. Identify barriers and facilitators 3. Create solutions to identified barriers 4. Evaluate the uptake of SBI in pilot sites Utilize CDC Draft SBI Implementation Guide

38 Participating partners Arctic FASD Regional Training Center (CBHRS, UAA) received a two-year award from CDC. Alaska Section of PHN: 24 public health centers plus itinerant nurses who support over 280 Alaska Native villages across the state. 3 PHN health centers (two urban and 1 rural) participated in the pilot.

39 What we did (Timeline of steps) Obtained organizational commitment from PHN Section Chief and Leadership team (March 2013) Formed a Planning team (April 2013) PHN quality improvement, informatics, training, nurse providers and managers, and UAA research team Decided on screening, brief intervention, referral and documentation processes (May 2013) Selected Screeners: T-ACE plus two NIAAA questions (CRAFFT for adolescents) Designated Eligible Visits: Gyn, Family Planning, Prenatal, Postpartum, STI, TB Designated staff roles: Who screens, who scores; where and when? Who delivers intervention; and when? Designed patient education materials/provider pocket guides and resources Drafted SBI policy and procedure and distributed it to 3 pilot sites

40 What we did (Timeline, continued) Trained health center staff at 3 pilot sites (June 2013) Conducted a pilot/collected data (July September 2014) Providers entered screening outcomes and contact notes in health records. Research team provided TA during regularly scheduled calls with pilot sites. Research team documented implementation process, provider feedback, and conducted key informant interviews with diverse PHN staff. Refined P&P throughout, shared data, implemented ideas Finalized P&P and Trained all PHNs to conduct alcohol SBI

41 Data Collected Reach (# of eligible patient visits receiving screening) Effectiveness (# of positive patients receiving a brief intervention or referral) Implementation process (used to monitor fidelity and refine protocols) Screening rates monitored throughout the study Chart reviews Field Notes from ongoing practice facilitation calls Key Informant Interviews Sustainability Provider satisfaction, perceived feasibility/effectiveness Formal policy and procedure for SBI Ongoing quality metrics and opportunities for staff training

42 100.0% Percent of Visits Screened for Risky Alcohol Use July 2013 September % 80.0% 70.0% 78.7% 60.0% 50.0% 56.5% 40.0% 30.0% 20.0% 10.0% 0.0% PHC 1 PHC 2 PHC 3 OVERALL Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

43 100.0% Percent of Screenings that Scored Positive for Risky Alcohol Use July 2013 September % 80.0% 70.0% 60.0% PHC 1 PHC 2 PHC 3 OVERALL 50.0% 40.0% 30.0% 32.4% 20.0% 23.6% 10.0% 0.0% Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

44 Implementation Process - get started Skills competence and confidence with SBI varied following training I think that [onsite training] made a difference in how easy it was for folks to incorporate it. [nurse interview] It s all about approach. Incorporate it as a part of the conversation. [training observation] trying to figure out a good way to talk about problem drinking or to talk about why we're asking all these questions. That can kind of take a little bit of thinking and just trying to figure out the best way to approach it for each person. [nurse interview] We should be asking these questions. I think it's right in there with our usual screenings or questions that we ask people regarding their well being and health habits. [nurse interview]

45 Implementation Process identify and address unforeseen issues quickly Documenting positive screens in patient charts met with some initial concern and resistance. Uncomfortable with the terminology- sounds too incriminating if records were released. [nurse, during a facilitation call] Let the people who actually work with clients decide what the wording should be. [nurse, during a facilitation call]

46 Implementation Process monitor fidelity, provide support Identified needs for continuous process improvement and skills practice/booster training I think it was the intervention piece that was, that's still the hardest part of it all. [nurse interview] my comfort level is getting stronger with more practice. [training observation]

47 Implementation Process update plans, integrate recommendations Competence and confidence improved over time I think initially it was challenging just because it was a change and it was a new form and a new way to question people. It s gotten a lot easier as we ve used it. [nurse interview] I have more tools to use. [nurse, during a facilitation call] Adapting and refining a draft P&P encouraged acceptance. I think it was helpful to see the process adapt as it went on, and that really empowered people for realizing that their experience and their voice did matter. And the process didn t change significantly as we went along, but there were improvements made. I think people felt that by the time it rolled out system-wide, it was a better process than it was when we started it as a pilot. [nurse manager interview]

48 Implementation Process Success stories Regarding a client in STD clinic we did the ETOH screen and talked briefly about family history. Apparently it hit a nerve because she returned to clinic 2 months later and saw a different nurse. She told him she had really taken the counseling to heart and was at that time 29 days sober. It was definitely a brief intervention, but for her it had an impact! Adolescent female client reported, I don t drink, I don t do drugs. Through screening the nurse found the client had a history of heavy alcohol use and was currently sober. The nurse mentioned she would not have learned about this information if SBI had not occurred. It really IS in HOW you ask the questions.

49 Alaska PHN Today alcohol SBI still going strong! As of October, 2016, policy still in place, actively monitoring quality: 73-78% eligible visits screened 7% of eligible visits deferred (goal is <5%) 27-32% of eligible visits screened positive However, 15-20% of eligible visits incomplete (i.e., no documentation of screening or deferment; investigating this) What contributed to sustaining alcohol SBI? Planning incorporated knowledge of what worked for other screenings (e.g., Domestic Violence; meaningful reporting) Piloting in a few PHC s to figure out the glitches Pilot led to development of supportive tools, refinement of policy PHNs knew about pilot and that alcohol SBI was coming Education and videos were put in place, so all new nurses get the same training

50 Final Points Alcohol SBI is a feasible, effective public health approach provides a low-intensity, low-cost clinical prevention service used to identify and intervene with people who drink too much Many who receive alcohol SBI respond positively and will reduce risks over time Clients not only asked about alcohol, but nurses have to talk to them about it, document, and follow-up Focus of BI on harm reduction, empowered nurses to intervene, reduce need to refer to treatment Implementing alcohol SBI requires planning and input from all levels of staff Drafting a written policy and procedure, that is piloted and refined prior to roll-out, enhances likelihood of success and sustainability Ongoing monitoring of adherence to screening protocols and improvement of brief intervention skills is key to assuring maximum reach and impact.

51 Acknowledgements Centers for Disease Control (project funder); Rhonda Richtsmeier, MN, RN (retired section chief), State of Alaska Public Health Nursing Linda Worman, DM, RN (current section chief), State of Alaska Public Health Nursing Arctic FASD-RTC project team, Becky Porter, project manager Marilyn Pierce-Bulger, ANP, CNM, project consultant and trainer

52 Position Statement on the Prevention of Alcohol Exposed Pregnancies

53 Why do organizations develop position statements? Address an identified issue relevant to mission statement and vision/goals Educate stakeholders about an issue Increase visibility as a leader concerning the issue Provide documentation of recommended actions to assist in obtaining support for related project/projects Provide documentation of recommended actions to assist in ongoing evaluation of achievements

54 NPWH s Mission is to ensure the provision of quality primary and specialty health care to women of all ages by women s health nurse practitioners and other women s health focused advanced practice registered nurses. Our mission includes protecting and promoting a woman's right to make her own choices regarding her health within the context of her personal belief system. NPWH s Vision is to strive to continuously improve access and quality of health care for women. This will be accomplished through excellence and innovation in continuing education and professional development; leadership in policy, practice and research; and through support and services for our members.

55 Writing Position Statements Initial Challenges Our BOD, CEO, and staff are dedicated to NPWH s mission and vision Our BOD, CEO, and staff are very, very busy We needed to agree on issues that should take highest priority We needed a plan for coordinating the process

56 Why Prevention of Alcohol Exposed Pregnancies? WHNPs see reproductive age women who are sexually active and not planning a pregnancy planning to become pregnant pregnant CDC Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices published in 2014 Opportunity to build partnerships with others with similar interests/goals

57 Developing Position Statements - Membership Engagement Writing Group Board of Directors Position Statement Reviewers Public Comment

58 Our Position Statement Format Statement of position Background information Implications for members and those they serve Recommendations for practice and advocacy Action organization will take to provide leadership and resources References Another challenge - Keeping it brief!

59 Step 1: The Writing Group Writing group recruitment Preparation of working draft for the writing group Additional resources/references obtained from writing group members Back and forth review and revision process

60 Step 2: Reviewers Recruitment of experts on the issue outside the organization Clinical specialists interdisciplinary Relevant national agency representatives Healthcare professionals involved in national level projects on the issue

61 Step 3: Public Comment NPWH Members and Affiliates

62 Step 4: NPWH Board of Directors Approval Does the position statement support the mission and vision of NPWH?

63 Getting Our Position Statement Out There Website Organization publications Conference and other meeting presentations Distribution to relevant policy makers and other organizations Virginia Henderson E-repository

64 Does a position statement make a difference? Done Survey of members prior to release of position statement regarding knowledge, skills, attitudes, behaviors related to the issue To Do Survey of members after release of position statement Collect data on types and number of stakeholders reached through dissemination venues Collect data on achievement of recommendations

65 Our Survey N = 216 What We Learned

66 % who responded frequently or always How often do you ask about alcohol use in your patients who are: sexually active and do not want to get pregnant in the next year, but are at risk for pregnancy? 72% planning a pregnancy within the next year? 84% are pregnant? 90% 64% have a protocol in place in their practice to screen all patients for their alcohol use.

67 % who answered very / completely confident in their skills to - ask women, including pregnant women, about their alcohol use. 87% identify levels of alcohol use considered risky in women. 69% conduct brief interventions for reducing alcohol use. 41% educate pregnant and non-pregnant women of reproductive age about the effects of alcohol on a developing fetus. 76%

68 % who agreed / strongly agreed with these statements Risky levels of drinking alcohol in women are considered to be > 4 drinks per occasion or > 7 drinks per week. 85% It is important to screen all pregnant women for alcohol use. 96% It is important to screen all women of reproductive age for alcohol use. 95% It is important to educate pregnant and non-pregnant women of reproductive age about the effects of alcohol on a developing fetus. 95% Alcohol is a teratogen. 95%

69 Next Steps Webinars to address identified gaps in knowledge and skills Continue to develop partnerships Development of other education and practice strategies to facilitate clinicians in their efforts to prevent of alcohol exposed pregnancies Evaluate outcomes

70 If we did all of the things we are capable of doing, we would literally astonish ourselves. Thomas Edison

71 Questions & Comment

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