PCP SBIRT Framework

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Contents

Key Details - Updated for Phase II

  • Title: Online Skills Training for Primary Care Physicians on Substance Abuse
  • Funding: NIDA Contract No. HHSN271200800038C
  • NIDA Contracting Officer: Quandra Scudder
  • Principal Investigator: T Bradley Tanner, MD
  • Co-Investigator: Mary P Metcalf, PhD, MPH
  • Project Director: Meghan Coulehan, MPH
  • Phase II Project Period: 9/21/09 - 9/21/11
  • Product: SBIRT Website, Name: TBD
  • SBIRT Progress Reports
  • Product: http://sbirt.clinicaltools.com/
  • Curriculum

Description

Primary care physicians (PCPs) are positioned to identify and treat at-risk use and substance abuse through the application of SBIRT (Screening, Brief Intervention, and Referral to Therapy). Online Continuing Medical Education (CME) with enduring materials has accelerating acceptance on the part of PCPs, clear cost effectiveness, and high availability. The applicant organization already provides effective CME-based training in at-risk use and addiction. We seek to affect SBIRT clinical skills of PCPs via a unique and easily scalable web-based training experience involving Internet chat and live Standardized Patients (SPs). Step-by-step guides, interactive coursework, and introductory videos, supplement the experience. A resource toolkit provides screening tools, patient education sheets, and tools to connect the PCP with a local specialized substance abuse treatment program. Phase I successfully completed a needs assessment, a curriculum outline of 5 modules, expert consultant review and revision, and usability testing. Phase II completes the development and usability testing and evaluates its effectiveness with 80 primary care physicians through a randomized, crossover control design using an Objective Structured Clinical Exam assessment. The eventual product will deliver an evidence-based, peer and expert reviewed CME experience that is easily available, cost-efficient, challenging, and easy to use.

Need

As many as 20% of primary care patients have substance use problems and primary care physicians could have a significant impact on their problems through providing screening, brief interventions, and referral to treatment (SBIRT) (Mersy, 2003). Brief interventions in primary care have been shown to reduce alcohol use, at least for 12 months, in non-dependent heavy drinkers and to increase the likelihood that heavy and dependent drinkers will follow-through with treatment (Babor et al, 2007). However, the reality is that few PCPs are routinely providing substance use screening and even fewer provide an intervention with their patients (Roche and Freeman, 2004; D'Amico et al., 2005). One reason is lack of adequate training (McLellan et al., 2000; Miller et al., 2001). Training needs to go beyond providing knowledge of clinical skills; it must provide an opportunity to integrate the knowledge through practice of newly learned skills (Butzlaff et al., 2004). Standardized patients have been used successfully to train physicians in screening and brief interventions (Wilk and Jenson, 2002), however, a scalable version is needed.

Vision

We will develop a state-of-the-art website where primary care physicians can find training in screening, brief intervention, and referral (SBIRT) skills for substance abuse as well as the opportunity to immediately practice those skills. We will also provide all the resources and networking opportunities they need in order to provide and integrate SBIRT for substance abuse into their practices. We will utilize technology to implement realistic and efficiently delivered interactive training models. The resulting website will be attractive and effective in improving the use of these skills and the frequency with which they are used.

Mission

Our website will increase the frequency with which primary care physicians screen for substance use problems, provide a brief intervention, and make a referral to treatment when appropriate. This will be achieved by expanding upon the experiences of successful SBIRT and similar programs and the latest evidence to create a state-of-the-art website that provides training to primary care physicians to enhance their skills in screening, brief intervention, and referral to treatment for substance abuse. We will provide the opportunity to repeatedly practice training in straightforward skills, such as the use of different screening tools, via simulated online interactive cases. We will provide the opportunity to practice more nuanced skills via live interviews with Standardized Patient actors using online chat. In both trainings, tailored feedback including brief instruction and resources will be provided based on user performance. The website will also provide resources and networking opportunities to support their integration of SBIRT for substance abuse into their practices. Because the training is web-based, it will be scalable for any group size - from the individual provider to whole organizations - and can be easily deployed in a manner convenient to the busy schedule of most PCPs.

Target Audience

Primary care physicians.

Constraints

  1. 5 months and 95K
  2. Learning must qualify for CME credit and impact clinical outcomes.
  3. Consultations with specialists are difficult to obtain.
  4. May need to include non-physician providers such as Physician Assistants and NPs in order to fully impact primary care.
  5. Physicians do not usually browse the web looking for sites, do not always follow recommendations, and are busy and unlikely to return to the website.
  6. There is not always material to support evidence-based content.
  7. Collaboration features of web-based software are always changing.
  8. Solution must fit within the vision of the CTI Learning Management System.
  9. Solution must directly respond to NIDA's RFP.
  10. Solution must match our original abstract.
  11. Curriculum:
    1. Time is limited in Primary Care
    2. Learner wants to retain regular patients
    3. Knowledge base can vary considerably between learners
    4. Learning styles vary

Strengths

  1. Addiction is an area of medicine for which primary care providers are not well-prepared, particularly in the counseling aspect of brief interventions
  2. Strong consensus clinical opinion has been defined by organized medicine that can drive the content where evidence-based medicine is not available.
  3. Can use a novel content management system (CMS) computer software environment that fits the task

Goal

Develop a practical, attractive, efficient, and efficacious web-based skills development training using live online standardized patient actors.

Objectives

Project Objectives

  1. Provide formative research and evaluation of current evidence-based resources being considered for the content of the program. Where evidence-based information is not available, we will use the best possible information having a strong clinical consensus and reviewed by a panel of experts.
  2. Provide in-depth evaluation of current technology and interest by the target audience and determine the feasibility of using a web-based Standardized Patient training program to increase the frequency of screening, brief intervention, and referral for substance abuse by PCPs by providing an environment to learn and then immediately practice these skills.
  3. Ensure the skills development program is easy and quick to use by the target population
  4. Manage the process of obtaining appropriate review for providing Continuing Medical Education (CME) and the distribution of earned CME credits. [PCPs can receive CME credit via standard educational curricula. We will also explore whether there is interest in receiving CME credit on a just-in-time basis.]
  5. Provide a connection between PCPs and local specialized substance abuse treatment programs.
  6. Provide an environment where PCPs can go to collaborate and answer point-of-care questions.
  7. Create and submit a summary report that includes the project plan for Phase II.

Phase II Technical Objectives

  1. Objective 1: Design and build web interface - We will design and develop an interface for delivering the course content, centered around the live, online Standardized Patient (SP) training experience. The educational delivery system will also encompass the didactic materials, course assessment, and tailored educational feedback materials, a searchable database of resources, a discussion forum, searchable specialist personal pages, and RSS news feeds of research abstracts.
  1. Objective 2: Develop content of skills training - We will fully develop step-by-step clinical guides for SBIRT for substance abuse in primary care and other introductory didactic materials for each of the five courses. We will also develop the Standardized Patient cases, scripts, assessments, and tailored educational feedback materials. We will also develop the resources data base including screening tools, patient education materials, physician locator information, and billing information. Expert consultants evaluate the curriculum.
  1. Objective 3: Conduct usability testing of the training and computer interface design - We will conduct usability testing of the training program with nine primary care physicians, which is the target audience. They will evaluate the design, navigation, layout, and ease of use of a prototype course in an interactive design. A third test with nine physician participants will evaluate the usability of the whole website.
  1. Objective 4: Evaluate training and website summatively - We will conduct a summative evaluation of the website and training once development is completed. We will enroll 80 primary care physicians in a randomized, cross-over, wait-list controlled trial. The assessment will be a pre- post- Objective Structured Clinical Examination (OSCE) that will be in addition to the SP learning experience. We will request from the Office of Management and Budget clearance to exceed 9 research subjects in the summative evaluation.
  1. Objective 5: Disseminate results - We will present findings from the usability testing and summative evaluation during and following completion of the project and will prepare a manuscript for publication in a peer reviewed literature. We will prepare a final report describing the product and the results of the evaluation.

Summary of formative research

  • Needs Analysis #1 (survey; max 9 PCP physicians)
  • Needs Analysis #2 (survey; max 9 PCP physicians)
  • Needs Analysis #3 (interviews, max 9 PCP physicians)
  • Usability - SP interface prototype (max 9 PCP physicians)
  • Consultant feedback on Curriculum, tools, resources, website plans, etc.

Alternative Solutions

  1. Expert opinion, needs analysis and user feedback may identify components which can be trimmed down.
  2. We may find existing resources which complete similar functionality thus eliminating the need for that component.
  3. As the courses will be scalable, we will later be able to adapt them to other clinical professions, starting with nurses, and later including physician assistants, physical therapists, dentists psychiatrists, social workers, psychologists, and other counselors.

Remote Standardized Patient (SP) Concept

We believe that remote SPs will be an important facet of the learning experience, based on an encouraging level of interest from the target audience in the needs analysis, information on target audience preferences, a review of the literature, and a review of information on the current use of non-remote standardized patients in educational settings. We have described this information in detail at [1]

Curriculum Overview

The final proposed curriculum plan includes 4 SP-based courses (3 "core" courses and 1 advanced course):

  1. Screening for Substance Abuse (Core Course)
  2. Brief Intervention for Substance Abuse (Core Course)
  3. Referral for Substance Abuse (Core Course)
  4. Advanced Cases in Screening-Brief Intervention-Referral

See [2].

Also planned: a non-credit introductory video, "SBIRT Succeeds!"

Evaluation Design

Success is defined as the successful completion of all objectives and the production of a Phase I report and Phase II proposal as well as a wire-frame (no design elements) mockup of the proposed website and interactive features. (See [3]).


Communication

We have found several good conferences to present our work in the past and they will be excellent for this project as well.


PCP SBIRT Framework

PCP SBIRT Training Components (Curriculum): Training in Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Use Problems

PCP SBIRT Curriculum References

SBIRT Progress Reports
October 2008 • November 2008 • December 2008 • January 2009 • February 2009 • March 2009 • October 2009 (Ph II)

Clinical Tools Frameworks

Consumers

Intermediaries

Health Researchers

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