Developing a Clinical Pathway to Improve School-Based Health Care

for Adolescent Substance Abuse

Mary M. Ramos, MD, MPH

Winona Stoltzfus, MD

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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.

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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

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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.

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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• 30% have been in car with impaired driver *2011-2012 SBHC data, unpublished

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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*2011-2012 SBHC data, unpublished

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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

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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

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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

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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

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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)

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CHISPA evaluation (instrument in pilot stage)

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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

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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

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Next Steps

• Pilot project begun

– One urban and one rural site

• Challenges

– Expand regionally

– Lack of resources

– Developing new tool

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Evaluation

• Process evaluation with providers

• Quantitative evaluation • Number screened

• Number assessed

• Outcomes

• Use evaluation to inform expansion of program

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Summing It Up

• Need or gap is identified

• Multidisciplinary approach is developed

• Flexible approach that is readily modified

• Evaluation is key

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