Developing a Clinical Pathway to Improve School-Based Health Care for Adolescent Substance Abuse Winona Stoltzfus, MD 1
Acknowledgments Mary M. Ramos, MD, MPH Envision New Mexico Terri Chauvet & McKane Sharff, MS Envision New Mexico Timothy P. Condon, PhD CASAA 2
Disclosures In compliance with the ACCME/NMMS Standards for commercial support of CME, as the presenter, I advise the audience that we have no relevant financial relationships to disclose. 3
What is a clinical pathway? Structured, multidisciplinary care plan Translates evidence-based practice into local care Way of responding to identified problem or gap in care Outlines the expected progress 4
Reasons to develop a clinical pathway Optimize patient care and outcome Curb widespread practice variation Provide a roadmap of care for providers, patients and other health care personnel. Treat/refer Assess Screen 5
Overview Problem: Adolescent Substance Abuse Gap: how to optimally use SBHC resources in response to this public health issue Clinical pathway: based on SBIRT model Reference: Substance Abuse Screening, Brief Intervention, and Referral to Treatment, Pediatrics 2011;128;e1330 6
Identifying the Problem: Adolescent Substance Abuse Among High School School-Based Health Center (SBHC) users in NM*: 60% have used alcohol 30% use marijuana or other drugs 30% have been in car with impaired driver *2011-2012 NMDOH SHQ data, unpublished NM leads US in many indicators of adolescent substance abuse (YRBS data) 7
Adolescent substance use, US and NM high school students Alcohol use, before 13 yrs old 27.4 Marijuana use, before 13 yrs old 18.5 Cocaine use, current 5.2 Cocaine use, ever Ecstacy use, ever 11.4 12.2 US NM Methamphetamine use, ever CDC 2011 YRBS data Heroin use, ever 4.7 5.5 0 5 10 15 Percent 20 25 30
Student Health Questionnaire (SHQ) Health screen used in NM SBHCs Includes CRAFFT, a validated tool to screen for adolescent substance abuse 9
CRAFFT * Endorsed by the American Academy of Pediatrics* CRAFFT elements C -ridden in a CAR driven by someone who was high? R use to RELAX? A use while ALONE? F - ever FORGET things you did while using? F- family or FRIENDS ever tell you to cut down on use? T - ever gotten into TROUBLE while using? * Pediatrics 2011;128;e1330 10
Student Health Questionnaire/CRAFFT 40% NM high school students who use SBHCs screen positive for substance abuse with CRAFFT *2011-2012 NM SBHC data, unpublished 11
Provider Practice: Variation and Under Treatment (1) In SBHCs, CRAFFT not recognized as a screen SBHC provider survey in 2012 Only 1 in 10 providers aware of CRAFFT 12
Provider Practice: Variation and Under Treatment (2) No validated assessment tool exists for primary care Variations in how providers assessing No developed standard of care Few referral sources 13
Methods: the Pathway Process Develop multidisciplinary team Review literature and clinical practice guidelines SBIRT Model: Screening, Brief Intervention, Referral and Treatment Study historical practice SBHC provider survey on practices SBHC Provider focus group Review electronic data on SHQ/CRAFFT screening 14
Methods Synthesize findings in regular meetings to generate the steps in the pathway Follow the SBIRT model Screen with SHQ (CRAFFT) Assess with CHISPA newly created tool Adapted from NIAAA Treat and Refer per level of risk 15
Clinical Pathway to Improve School-Based Health Care for Adolescent Substance Abuse Screen Students > 14 yrs CRAFFT (embedded in SHQ) Negative (<1 + response) Car question positive? Give brief response Offer Contract for Life Positive (>2 + responses) Reinforce continued good choices and safety Assess Administer CHISPA Determine level of risk Lowest Concern Treat Brief motivational interviewing by PC or BH SBHC provider Moderate Concern Treat/Refer Brief motivational interviewing by BH SBHC provider; consider referral Highest Concern Refer Brief motivational interviewing by BH SBHC provider and referral 16
Methods Develop and evaluate a pilot program Two SBHC sites: one urban, one rural Trainings for SBHC providers Screening Assessment (using new tool) Brief Intervention (Motivational Interviewing) Referral Evaluate the Clinical Pathway 17
Clinical pathway Intended Outcome Simple, useable format and tools Accompanying handbook for SBHC providers (reference handbook) and for students SBHC providers supported by: tools, trainings, TA, QA/QI referral sources or consults as needed 18
Outcome Continued Measurable Impact on Care for Adolescent Substance Abuse SBHCs in NM to provide appropriate care in more consistent manner Optimize existing health resources (SBHCs and academic partners) to address this adolescent health problem 19
Next Steps Pilot project begun Evaluate pilot Challenges Expand regionally Developing resources Developing and validating new tool 20
Evaluation Formative evaluation with providers Screening, assessment tool, referrals, treatment Quantitative evaluation Numbers screened, assessed, referred for care outside the SBHC or treated at SBHC. Use evaluation to inform expansion of program 21
Summing It Up Identified a need and gap in care. Using a multidisciplinary approach. Approach is flexible and is readily modified Critical assessment is key 22