developing a clinical pathway to improve school-based ... · 11 clinical pathway to improve school...
TRANSCRIPT
Developing a Clinical Pathway to Improve School-Based Health Care
for Adolescent Substance Abuse
Mary M. Ramos, MD, MPH
Winona Stoltzfus, MD
1
Contributing Members
• McKane Sharff, MS
Envision New Mexico
• Timothy P. Condon, Ph.D.
CASAA
• This event is jointly sponsored by the HealthInsight New Mexico and
NMPHA & NM CARES Health Disparities Center.
• In compliance with the ACCME/NMMS Standards for commercial support of CME, as the presenter, we (Winona Stoltzfus and Mary Ramos) hereby advise the audience that we have no relevant financial relationships to disclose.
2
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
3
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.
4
Treat/refer
Assess
Screen
Identifying the Problem
• Substance abuse an important adolescent health problem in NM
• NM leads US in many indicators of adolescent substance abuse (YRRS data)
• Among High School School-Based Health Center (SBHC) users in NM (SHQ data*):
• 60% have used alcohol
• 30% use MJ or other drugs
• 30% have been in car with impaired driver *2011-2012 SBHC data, unpublished
5
Student Health Questionnaire
• Screening tool used in NM SBHCs
• CRAFFT embedded in tool
• 40% positive screen* by NM
high school students
*2011-2012 SBHC data, unpublished
6
CRAFFT
• Validated tool to screen for adolescent substance abuse (AAP*)
• 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
7
Provider Practice • Significant practice variation and under treatment
• In SBHCs, CRAFFT not recognized as a screen
• Only 1 in 10 providers aware
• No validated assessment tool exists for primary care
• No developed referral sources or standard of care
8
Methods: the Pathway Process
• Develop multidisciplinary team
• Review literature and ‘clinical practice guidelines’
• Grading of evidence, strength of recommendation
• Study historical practice
• SBHC provider survey on practices
• SBHC Provider focus group
• Electronic data on SHQ/CRAFFT screening and diagnoses
9
More on Methods
• Synthesize findings in regular meetings to generate the steps in the pathway
– Screen with SHQ
– Assess with CHISPA
– Treat and Refer per level of risk
• Develop and evaluate a pilot program
– Evaluate the Clinical Pathway using mixed methods
– Pilot in two sites, one urban one rural
– Develop resource list
10
11
Clinical Pathway to Improve School-Based Health Care for Adolescent Substance Abuse
Screen Students > 14 yrs
CRAFFT (embedded in SHQ)
Negative (<1 + response) 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
“Car” question positive? Give brief response
Offer Contract for Life
CHISPA instrument (instrument in pilot stage)
12
CHISPA evaluation (instrument in pilot stage)
13
Intended Outcome
• Clinical pathway
• 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
14
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
15
Next Steps
• Pilot project begun
– One urban and one rural site
• Challenges
– Expand regionally
– Lack of resources
– Developing new tool
16
Evaluation
• Process evaluation with providers
• Quantitative evaluation • Number screened
• Number assessed
• Outcomes
• Use evaluation to inform expansion of program
17
Summing It Up
• Need or gap is identified
• Multidisciplinary approach is developed
• Flexible approach that is readily modified
• Evaluation is key
18