Implementation and Quality Improvement of a Screening and Counseling Program for Unhealthy Alcohol Use in an Academic General Internal Medicine Practice

Unhealthy alcohol use is the third leading cause of preventable death in the United States (U.S.). The U.S. Preventive Services Task Force recommends screening for unhealthy alcohol use but little is known about how best to do so. We used quality improvement techniques to implement a systematic approach to screening and counseling primary care patients for unhealthy alcohol use. Components included use of validated screening and assessment instruments; an evidence-based 2-visit counseling intervention using motivational interviewing techniques for those with risky drinking behaviors who did not have an alcohol use disorder (AUD); shared decision making about treatment options for those with an AUD; support materials for providers and patients; and training in motivational interviewing for faculty and residents. Over the course of one year, we screened 52% (N=5,352) of our clinic’s patients and identified 294 with positive screens. Of those 294, appropriate screening-related assessments and interventions were documented for 168 and 72 patients, respectively. Although we successfully implemented a systematic screening program and structured processes of care, ongoing quality improvement efforts are needed to screen the rest of our patients and to improve the consistency with which we provide and document appropriate interventions

Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design

<p>Abstract</p> <p>Background</p> <p>Unhealthy substance use is the spectrum from use that risks harm, to use associated with problems, to the diagnosable conditions of substance abuse and dependence, often referred to as substance abuse disorders. Despite the prevalence and impact of unhealthy substance use, medical education in this area remains lacking, not providing physicians with the necessary expertise to effectively address one of the most common and costly health conditions. Medical educators have begun to address the need for physician training in unhealthy substance use, and formal curricula have been developed and evaluated, though broad integration into busy residency curricula remains a challenge.</p> <p>Discussion</p> <p>We review the development of unhealthy substance use related competencies, and describe a curriculum in unhealthy substance use that integrates these competencies into internal medicine resident physician training. We outline strategies to facilitate adoption of such curricula by the residency programs. This paper provides an outline for the actual implementation of the curriculum within the structure of a training program, with examples using common teaching venues. We describe and link the content to the core competencies mandated by the Accreditation Council for Graduate Medical Education, the formal accrediting body for residency training programs in the United States. Specific topics are recommended, with suggestions on how to integrate such teaching into existing internal medicine residency training program curricula.</p> <p>Summary</p> <p>Given the burden of disease and effective interventions available that can be delivered by internal medicine physicians, teaching about unhealthy substance use must be incorporated into internal medicine residency training, and can be done within existing teaching venues.</p

Ask, Advise, Assist and Follow: An Evidence Based Project to Address Unhealthy Alcohol Use in a Free Clinic Setting

Preventative care in free clinic settings aims to mitigate health risks for vulnerable populations. Heavy alcohol intake is a major threat to physical and mental health. Wellness care for free clinic patients must include regular screening for alcohol use in accordance with national guidelines. The purpose of this project was to implement and evaluate an evidence- based practice change to improve alcohol screening and intervention in a free clinic setting. The NIH/NIAAA screening, brief intervention, and referral for treatment (SBiRT) process was implemented. A convenience sample of de-identified patient charts was reviewed to assess alcohol screening before (n = 38 charts) and after (n = 30) a staff education intervention; data collected (n = 68) did not include demographic or patient identifiers to protect privacy. Comparison of HEDIS scores before and after intervention showed improved alcohol screening and intervention/referral for treatment rates

Barriers to recruiting primary care practices for implementation research during COVID-19: A qualitative study of practice coaches from the Stop Unhealthy (STUN) Alcohol Use Now trial

Background: The COVID-19 pandemic has brought widespread change to health care practice and research. With heightened stress in the general population, increased unhealthy alcohol use, and added pressures on primary care practices, comes the need to better understand how we can continue practice-based research and address public health priorities amid the ongoing pandemic. The current study considers barriers and facilitators to conducting such research, especially during the COVID-19 pandemic, within the context of recruiting practices for the STop UNhealthy (STUN) Alcohol Use Now trial. The STUN trial uses practice facilitation to implement screening and interventions for unhealthy alcohol use in primary care practices across the state of North Carolina. Methods: Semistructured interviews were conducted with a purposive sample of 15 practice coaches to discuss their recruitment experiences before and after recruitment was paused due to the pandemic. An inductive thematic analysis was used to identify themes and subthemes. Results: Pandemic-related barriers, including challenges in staffing, finances, and new COVID-19-related workflows, were most prominent. Competing priorities, such as quality improvement measures, North Carolina's implementation of Medicaid managed care, and organizational structures hampered recruitment efforts. Coaches also described barriers specific to the project and to the topic of alcohol. Several facilitators were identified, including the rising importance of behavioral health due to the pandemic, as well as existing relationships between practice coaches and practices. Conclusions: Difficulty managing competing priorities and obstacles within existing practice infrastructure inhibit the ability to participate in practice-based research and implementation of evidence-based practices. Lessons learned from this trial may inform strategies to recruit practices into research and to gain buy-in from practices in adopting evidence-based practices more generally. Plain Language Summary What is known: Unhealthy alcohol use is a significant public health issue, which has been exacerbated during the COVID-19 pandemic. Screening and brief intervention for unhealthy alcohol use is an evidence-based practice shown to help reduce drinking-related behaviors, yet it remains rare in practice. What this study adds: Using a qualitative approach, we identify barriers and facilitators to recruiting primary care practices into a funded trial that uses practice facilitation to address unhealthy alcohol use. We identify general insights as well as those specific to the COVID-19 pandemic. Barriers are primarily related to competing priorities, incentives, and lack of infrastructure. Facilitators are related to framing of the project and the anticipated level and type of resources needed to address unhealthy alcohol use especially as the pandemic wanes. Implications: Our findings provide information on barriers and facilitators to recruiting primary care practices for behavioral health projects and to implementing these activities. Using our findings, we provide a discussion of suggestions for conducting these types of projects in the future which may be of interest to researchers, practice managers, and providers

Screening for Alcohol Use, Misuse, or Abuse in the Primary Care Setting using the AUDIT-C tool: An Extension Study

Abstract PURPOSE: The purpose of this study was to improve alcohol screening rates in one primary care setting by educating and supporting providers and office staff on the use of the Audit-C alcohol screening tool. METHODS: This study design was a Quasi-Experimental intervention, one group post-test. Data was collected utilizing a retrospective chart review from the electronic medical records of adults over age 18 years by visit type: New Patient Visit, Annual Visit, or Employee Wellness Exam. Data included: demographic data of patient age, race, gender, the Audit-C score, and whether or not an intervention was performed. RESULTS: Five providers (three APRN and two MDs) consented to participate. Of the 100 patient charts reviewed, 33 had an AUDIT-C score documented by a provider. The Audit-C scores ranged from 0-5. Fifty-six percent of females and 20% of males scored high enough for a brief intervention. Three intervention types were found (Counseling, patient declines/no intervention results not documented) with the most common type being counseling. CONCLUSION: The use of the Audit-C in a primary care setting was shown. Office Staff and providers successfully demonstrated the ability to complete the Audit-C tool and indicated interventions within standard appointment times. Further studies to examine the impact of adding the Audit-C to an EMR and its impact on screening rates is warranted

Improving Screening For Alcohol Use Amongst Women in Primary Care

Purpose: The purposes of this practice inquiry project were to examine the effect of the addition of a standardized screening tool (AUDIT-C) within the ambulatory electronic health record (AEHR) and the effect of an education session with primary care providers on documentation of alcohol screening and counseling within the AEHR. Furthermore, provider confidence with Screening, Brief Intervention, and Referral to Treatment (SBIRT) was compared before and after the educational session. Methods: A quasi-experimental one-group pretest posttest design was utilized via chart review prior to and following the educational intervention for patients seen for an annual wellness exam. Data extracted included any alcohol screening performed as well as any subsequent education in the event of a positive alcohol screen. Provider confidence was assessed via questionnaire utilizing a Likert scale in relation to various SBIRT practices. The questionnaire was administered immediately prior to and 3 months post-intervention. Results: Assessment of alcohol use with a standardized screening tool increased from 44% to 74%, a statistically significant increase. For those who stated that they did consume alcohol, documentation of frequency of alcohol use improved. Statistically significant increases were noted in the assessment of number of drinks consumed per drinking day and the assessment of binge drinking. Among positive alcohol use screenings, documentation of an additional detailed assessment of use as well as documentation of alcohol use counseling improved. Provider confidence overall improved for general screening practices, but provider confidence decreased for practices specific to alcohol dependent or hazardous alcohol consuming patients. Conclusion: Alcohol use screening and provider confidence with general screening practices improved after the addition of the AUDIT-C to the AEHR and the training session. This program could serve as a model for adoption of other primary care clinics. Given that provider confidence decreased overall in relation to counseling and intervention for patients who screen positive for hazardous or dependent alcohol use, additional education is necessary on brief intervention and resources for referral

Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum

<p>Abstract</p> <p>Background</p> <p>This article, developed for the Betty Ford Institute Consensus Conference on Graduate Medical Education (December, 2008), presents a model curriculum for Family Medicine residency training in substance abuse.</p> <p>Methods</p> <p>The authors reviewed reports of past Family Medicine curriculum development efforts, previously-identified barriers to education in high risk substance use, approaches to overcoming these barriers, and current training guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and their Family Medicine Residency Review Committee. A proposed eight-module curriculum was developed, based on substance abuse competencies defined by Project MAINSTREAM and linked to core competencies defined by the ACGME. The curriculum provides basic training in high risk substance use to all residents, while also addressing current training challenges presented by U.S. work hour regulations, increasing international diversity of Family Medicine resident trainees, and emerging new primary care practice models.</p> <p>Results</p> <p>This paper offers a core curriculum, focused on screening, brief intervention and referral to treatment, which can be adapted by residency programs to meet their individual needs. The curriculum encourages direct observation of residents to ensure that core skills are learned and trains residents with several "new skills" that will expand the basket of substance abuse services they will be equipped to provide as they enter practice.</p> <p>Conclusions</p> <p>Broad-based implementation of a comprehensive Family Medicine residency curriculum should increase the ability of family physicians to provide basic substance abuse services in a primary care context. Such efforts should be coupled with faculty development initiatives which ensure that sufficient trained faculty are available to teach these concepts and with efforts by major Family Medicine organizations to implement and enforce residency requirements for substance abuse training.</p

Using Screening, Brief Intervention, Referral to Treatment to Address Problematic Alcohol Use at a University Student Health Center

Problematic drinking is a public health concern on college campuses. College students who do not have their risky drinking behaviors addressed are at greater risk for developing Alcohol Use Disorder (AUD). Despite known risks associated with drinking on college campuses, many college health centers miss an opportunity to address these behaviors because they lack a systematic process for identifying students at risk and referring them for treatment. This evidence-based project evaluated the effectiveness of using Screening, Brief Intervention, Referral to Treatment (SBIRT) to identify students with risky drinking behaviors and the impact the screening process had on facilitating a referral to treatment. Students (n=172) were screened using the Alcohol Use Disorders Identification Test- Consumption (AUDIT-C), as part of the check-in process when they presented for a wellness exam at a university student health center in the southeastern United States. Students’ drinking behaviors were categorized as low-risk, at-risk or high-risk based on their AUDIT-C scores. Outcome measurement results indicated that use of a systematic process for screening students for alcohol use was effective at identifying students with risky drinking behaviors, provided a structured process to giving students feedback about their drinking behaviors and facilitated a referral to treatment for those students who scored in the high-risk category

Alcohol Screening, Brief Intervention, and Referral to Treatment Protocol in the Emergency Department

Background: The impact that results from inappropriate alcohol consumption poses challenges to public health. The rate of alcohol-related visits to the Emergency Department (ED) has increased, which has resulted in an increased annual cost of alcohol-related visits. ED serves as a common portal of entry into the healthcare system for many patients and offers a unique opportunity to impact drinking behaviors. Objectives: To increase the number of alcohol screenings and brief interventions when indicated to adult patients who visit the ED and increase ED nurses\u27 knowledge regarding alcohol misuse and indications for brief interventions. Methods: An educational module was delivered through the hospital\u27s E-learning management system. Ten multiple-choice pretest/post-test questions were administered to the ED nurses. A consecutive sample of ED patients, 18 years and older, over a 3-month period was used. A 3 single-item screening questions were programmed into the ED electronic health record to detect alcohol use disorder. Patients with positive screening, a score above 7 were flagged to alert peer recovery coaches to provide brief intervention and referral to treatment. Results: Seventy-nine nurses, representing 91% of the total number of ED nurses, completed the educational module. A dependent sample t-test indicated a statistically significant gain in nurse’s knowledge (t (78) = 15.91, p \u3c .01). The screening was conducted with 11,897 of 13,529 eligible patients, an 87% screening rate. Conclusion: The findings from this study were encouraging to support the effect of an educational module on ED nurses\u27 knowledge, and that an SBIRT procedure can impact alcohol use disorder through early identification