The SBIR Demonstration Project Appendix C:...

SBIRDemonstrationProject Page1

TheSBIRDemonstrationProjectImplementingScreening,BriefInterventionandReferralinCollaborative

CareSettingsinHalifax,NovaScotia

FINALREPORTPreparedby

WandaMcDonaldandDr.AnnetteElliottRose,Co-leads

ErinCasey,ProjectCoordinator

LisaJacobs,ProjectEvaluator

January2017


AppendixC:BrochureforPatients


TheSBIRDemonstrationProjectImplementingScreening,BriefInterventionandReferralinCollaborative

CareSettingsinHalifax,NovaScotia

FINALREPORT

TableofContents

Acknowledgements …5

KeyContributors …6

SBIRProject:BriefSummary …7

1.Introduction …9

2.Background …9

3.EvidenceinSupportofSBIR …11

4.AbouttheSBIRDemonstrationProject …14

5.ProjectEvaluation …19

6.MovingForward …32

AppendixA:SBIRAlgorithms …35

AppendixB:SBIRAlgorithmBookmark …37

AppendixC:BrochureforPatients …38

AppendixD:DataCollectionPointsandPurpose …39

Bibliography …40


ACKNOWLEDGEMENTSThisprojectwastheresultofthecollaborativeeffortofmanydedicatedpeopleandorganizationssharingtheirexperienceandexpertise.ItwasapleasuretoexchangeknowledgeandideasinourexplorationofhowtobestsupportScreening,BriefInterventionandReferral(SBIR)forpregnantpatientsandnewmothersinprimarycaresettings.

Thisprojectwouldnothavebeenpossiblewithoutthesubstantialcontributionsoftheindividualsandorganizationslistedbelow.

TheSBIRSteeringCommittee

ProjectCo-leadWandaMcDonaldManagerofAddictionsServicesNSDepartmentofHealthandWellness

ProjectCo-leadDr.AnnetteElliottRosePerinatalNurseConsultantReproductiveCareProgram,IWKHealthCentre

ErinCaseyProjectCoordinator

LisaJacobsSeniorEvaluatorNSDepartmentofHealthandWellness

LynnMacNeilKnowledgeExchangeCoordinatorNSDepartmentofHealthandWellness

RachelBoehmProgramLeader,AddictionsCapitalHealthAddictionsandMentalHealthProgram

GlendaCarsonPerinatalClinicalNurseSpecialistIWKHealthCentre

Dr.LynnBusseyHeadofObstetricsSpryfieldFamilyMedicineClinic

TrenaSlaunwhite-GallantPre-andPost-NatalEducatorChebuctoFamilyCentre

SusanShaddickActingProgramLeaderCommunityMentalHealth(CentralZone)

AliyahAlIslamCommunity/patientrepresentative

DonnaMaloneProgramConsultantPublicHealthAgencyofCanada(PHAC)

Consultingcommitteemember:Dr.RyanSommersMedicalOfficerofHealthforNSHANorthernZoneSBIRClinicalChampionforCFPC


Otherkeycontributors

Dr.MichaelVallis,healthpsychologistandleadresearcherattheBehaviourChangeInstitute,Halifax,NSDr.JoannaZedandDr.MathewGrandy,andthephysicians,residents,students,nurses,andstaffattheSpryfieldandMumfordDalhousieFamilyMedicineClinicsThefamiliesandstaffoftheChebuctoFamilyCentreinSpryfield,NSThisdemonstrationprojecthasbeenmadepossiblethroughafinancialcontributionfromHealthCanada’sDrugTreatmentFundingProgram(DTFP).TheviewsexpressedhereindonotnecessarilyrepresenttheviewsofHealthCanada.


SBIRDemonstrationProject:BRIEFSUMMARYScreening,BriefInterventionandReferral(SBIR)isanevidence-basedapproachdesignedforprevention,earlyintervention,andtreatmentofproblembehaviours.Itinvolvesscreeningallpeopleforaparticularproblemorproblemsastheyenternon-specializedsettings,brieflyinterveningtosupportbehaviourmodification,andreferringpatientsforappropriatetreatmentifneeded.

ThisreportdescribesthefindingsoftheSBIRDemonstrationProject,whichranfromMarch2015toMarch2016.ThepurposeoftheProjectwastoformallyintroduceandsupportusingSBIRinacollaborativeprimarycaresettingtoaddresssubstanceuse(SU)andmentalhealth(MH)forpregnantpatientsandnewmothers.Theobjectivesoftheprojectincluded:

Ø UsingSBIRtoidentifyproblematicSUandMHconcernsinpregnancyandnewmotherhood,Ø ImprovingawarenessandknowledgeamongprimarycareprovidersofperinatalSUand

MHconcerns,Ø Facilitatingevidence-based,empathetic,andcomprehensivesolutionsforproblematicSU

andMHissuesusingrelationalcareandtrauma-informedcarepractices,Ø Connectingpregnantpatientsandnewmotherswithsupportsandservices,andØ Understandingwhattoolsandsupportsarerequiredinprimarycaresettingsto

facilitateuptakeofSBIRbyhealthcareproviders

Evidencesupportsearlyidentificationandinterventionforriskysubstanceuse,particularlyalcohol,andforlowtomoderatelevelsofdepression.Effectiveandaffordableearlyinterventions,suchasMotivationalInterviewing(MI)-basedbriefinterventionsformoderaterisksubstanceuseandCognitiveBehaviouralTherapy(CBT)forlow-moderatelevelsofdepression,aresupportedbytheresearchliterature.DespitetheevidenceforSBIR,itsuseinprimarycaresettingsremainslow.Primarycarephysicians,nurses,andotherhealthprovidersneedopportunitiesandresourcestocreatepracticalsolutions.

Basedonnationaldata,10.5%to17%ofwomensmokedinpregnancy,10.5%to14%consumedalcoholinpregnancy,and5%reportedusingillicitdrugsinpregnancy.Asmanyastwo-thirdsofwomenwithsubstanceuseproblemsalsohavementalhealthproblems.Inaddition,awomanisatthehighestriskinherlifetimeofdevelopinganewmentalillnessinthefirstyearafterababyisborn.Peoplewhoarepregnantormotheringandhavechallengeswithsubstancesandmentalhealthareoftenstigmatized.

TheSBIRProjectwasguidedbytheprincipalsofrelationalcare,woman-andfamily-centredcare,andtrauma-informedcare.Theemphasisisonrecognizingtheimportanceandimpactofrelationshipsinwomen’slives,includingrelationshipswithhealthcareproviders,andacknowledgingtheimpactoftraumaandlivedexperienceonwomenandtheirfamilies.

Partnersandstakeholdersintheprojectincluded:

• MentalHealthandAddictionServicesintheNovaScotiaHealthAuthority• SpryfieldandMumfordDalhousieFamilyMedicinecollaborativecareclinics• BehaviourChangeInstitute• ChebuctoFamilyCentre


• ProjectteamandSteeringCommittee

Thefollowingtools,training,andothersupportsweredevelopedduringtheProjecttosupportprimaryhealthcareproviders(PHCPs),includingphysicians,nurses,andmedicalresidents,tointegrateSBIRintotheirpractice:

• Decision-basedalgorithmstohelpPHCPslearntoask,listen,summarize,andinvitepatientstochangeproblembehaviours:twodetailedlong-formtools,andonebookmark-sizedtool

• TrainingsessionsforPHCPstolearnaboutanddeveloptheirMIskills• Abrochureforpatients,tointroduceSBIRandpreparethemforaconversationabouttheir

care• Weeklyreminderemailscontaininginformationandprompts

Developmentalevaluationwasusedtodeepentheunderstandingofwhat,ifanything,PHCPsfindhelpfulinsupportingtheuptakeofSBIR.Somekeylearningsinclude:

1. Lackoftimeandcompetingprioritieswereseenassignificantbarriersforprimaryhealthcareprovidersto“doingSBIR”.ThetrainingmayneedtoberevisedtoplacegreateremphasisontheSBIRapproach,ratherthanSBIRtools,sothatSBIRisbetterintegratedintothemedicalappointmentandnotseenasanadd-on.

2. Mandatoryfollow-uptrainingisworthtrying.ThesecondtrainingsessioncouldemphasizedoingBriefInterventionandsupportingPHCPstolearnhowtoeffectivelyworkwithambivalencefrompatients.

3. SBIRmaynotneedtobeusedateveryprenatalvisitwitheverypatient.SBIRshouldbeusedwithallpatients,notjustthosewhoappeartobe“atrisk”.However,careproviderscanexercisegoodjudgmentaboutthefrequencyofusingSBIR,dependingontheirrelationshipwiththepatient.Continuingtoaskpregnantpatientsatregularintervalsisimportantbecauselivesandhabitschange,andpatientsmaybemorelikelytospeakopenlyaboutsubstanceuseormentalhealthwhentheyhavevisitedthecareproviderrepeatedly.

4. SupportingSBIRresources,suchasthealgorithms,brochure,videos,andemailreminders,werehelpfultoPHCPs.

5. PHCPsarebeingaskedtochangethewaytheypracticeandinteractwiththeirpatients;developingcomfortandconfidenceusingSBIRtakestime.TraininginandpromotionofSBIRcanacknowledgethisupfronttoallowPHCPstofeelcomfortableadaptingtheapproachtofittheirpracticestylesandlevelsofknowledgeandexperience.

6. HowSBIRwasusedinoneclinic–nursesusingSBIRandthennotifyingphysiciansiftheyscreenedforanissue–isworthexploringfurther.

7. Addressingsystem-levelissuessuchasrevisionstotheprenatalrecord(PNR)couldinfluencetheuptakeofSBIR.

Overall,therewasstrongsupportforfurtherdevelopmentofanSBIRapproachtoworkingwithpregnantpatientsandnewmothers.Itisimportanttonotethatalthoughthetwoclinicsmaydifferfromotherprimarycaresettings(theyareteachingsitesforfamilypracticeresidents,co-locatedwithorhavereadyaccesstoservices,andhaveanacademicfundingmodel),theorganizationanddeliveryofprenatalcareisverysimilartoothersitesintheprovince.PilotingSBIRinavarietyofprimaryhealthcaresettingsinNovaScotiaisanobviousnextsteptoarriveataclearerpictureofwhatmight“work”forsuccessfulimplementationofSBIRinNovaScotia.


1. INTRODUCTIONScreening,BriefInterventionandReferral(SBIR)isanevidence-basedapproachdesignedforprevention,earlyintervention,andtreatmentofproblembehaviours.Itinvolvesscreeningallpeopleforaparticularproblemorproblemsastheyenternon-specializedsettings,brieflyinterveningtosupportbehaviourmodification,andreferringpatientsforappropriatetreatmentifneeded.Itcanbeappliedinmanydifferentmedicalorsocialservicesettingsandtoadiverserangeofconcerns.Itisparticularlyappropriateformildtomoderateissues,withafocusonpreventionandusingtechniqueslikemotivationalinterviewing(MI)andcognitive-behaviouraltherapy(CBT).Asapublichealthmeasure,thegoalofSBIRistointerveneasearlyaspossiblewhenconcernsareidentified,andaddressthoseconcernswithintheprimaryclinicalorcounselingrelationshipwhenpossible.Thisreportdescribesthebackground,description,evaluativeprocess,andfindingsoftheSBIRdemonstrationprojecttargetingpregnantpatientsandnewmothersintwocollaborativeprimarycareclinicsinHalifax,NovaScotia.ItalsoincludessuggestionsandideasformovingforwardwithSBIRintheprovinceandtheregion.ThekeyobjectiveofthisprojectwastogainanunderstandingofwhattoolsandsupportsarerequiredinprimarycaresettingstofacilitateuptakeofSBIRbyphysicians,medicalresidents,andnurses.

2. BACKGROUNDInthefallof2008,HealthCanadaannouncedtheDrugTreatmentFundingProgram(DTFP).ThegoaloftheDTFPistomakeimprovementstoaddictionservicessystemsandhelpprovincesandterritoriesaddresscriticalissues.DTFPfundingflowsfromHealthCanadatotheNovaScotiaDepartmentofHealthandWellness(DHW).ConsultationwiththeNovaScotiaHealthAuthorities(nowamalgamatedintooneprovincialhealthauthority)informedtheDTFPproposalthatfundedthisSBIRDemonstrationProject.

Alsoin2008,NovaScotiacommissionedanEnvironmentalScanExploringSystemicBarriersforScreeningandBriefInterventionforPrimaryHealthCareProviders(NovaScotiaDepartmentofHealthProtectionandPromotion).BarriersidentifiedtousingSBIRforaddictionissuesincludedthefollowinglacks:time,remunerationinafee-for-serviceenvironment,priorityplacedonscreeningforaddiction,training,tools,comfortinaddressingaddictionwithpatients,patientdisclosure,andinterestinprovidingaddictionscreeningandintervention.Thereportconcludedthatwhiletherearenosimplesolutionstotheseissues,thebenefitsandopportunitiesofusingSBIRinprimaryhealthcaresettingsareprovenandwellworthworkingtowardaspartofacomprehensiveapproachtoaddictioncare.

ChangingtheCultureofAlcohol:AnAlcoholStrategytoPreventandReducetheBurdenofAlcohol-RelatedHarminNovaScotia(NovaScotiaDepartmentofHealthPromotionandProtection,AddictionServicesAlcoholTaskGroup)waspublishedin2007.AlcoholuseisasignificantburdenontheNovaScotiaeconomyintermsofbothdirectimpactonhealthcareandcriminaljusticecostsandindirectimpactonproductivityresultingfromdisabilityandprematuredeath.ThestrategyprovidedaroadmapforsupportingresponsibilityandriskreductionandincludedSBIRamongitsrecommendations.“Implementinganddeliveringscreeningandbriefinterventionsindifferent


kindsofprimarycaresettingsrepresentsauniqueopportunitytoreachNovaScotianswhootherwisewouldnotseektraditionaltreatmentservicesforaddictions.Primaryhealthcareprovidersarewellpositionedtoscreenforheavyandhigh-riskalcoholuseduringroutineclinicalencounters”(p.27).Inaddition,tosupporthealthcareservicesforproblematicalcoholuse,ReducingAlcohol-RelatedHarminCanada(NationalAlcoholStrategyWorkingGroup,April2007)recommendsthedevelopmentandimplementationofintegrated,culturallysensitivescreening,briefintervention,andreferral(SBIR)toolsandstrategies.Canada’sLow-RiskAlcoholDrinkingGuidelines(LRDGs)wererolledoutbytheCanadianCentreonSubstanceAbuse,onbehalfoftheNationalAlcoholStrategyAdvisoryCommittee(Canada'slowriskalcoholdrinkingguidelines,2012).TheLRDGsweredevelopedtohelpCanadiansmoderatetheiralcoholconsumptionandreducealcohol-relatedharms.InNovaScotia,specificLRDGbrochuresdevelopedaboutalcoholandpregnancy,aswellasalcoholandbreastfeeding,wereespeciallyvaluabletothisproject.BuildingonextensiveliteraturefocusedonthesuccessofSBIRapproaches(Berger&Bradley,2015)(Babor,McRee,Kassebaum,Grimaldi,Ahmed,&Bray,2007)(Agerwala&McCance-Katz,2012)(Madras,Compton,Avula,Stegbauer,Stein,&Clark,2009),theAlcoholScreening,BriefIntervention&Referral:Helpingpatientsreducealcohol-relatedriskstoolwaslaunchedbytheCollegeofFamilyPhysiciansofCanada(CFPC)(2012)andtheCanadianCentreonSubstanceAbuse(CCSA).Atthatpoint,conversationsstartedhappeningacrossthecountryaboutimprovingSBIRuptakeinthehealthsystem.TheSocietyofObstetriciansandGynecologistsofCanada(JOGC,2010)recommenduniversalscreeningforsubstanceuseforallwomenofchildbearingageandallpregnantwomen.In2013,theCCSApublishedLicitandIllicitDrugUseDuringPregnancy:Maternal,NeonatalandEarlyChildhoodConsequences,whichrecommendscomprehensive,multidisciplinarytreatmentservicesforpregnantwomen(Finnegan,2013).ThisintegratedapproachisalignedwiththementalhealthandaddictionstrategyfortheprovinceofNovaScotia,whichidentifiedtheneedtoenhancecollaborativecareamongprimaryhealth,mentalhealthandaddictionproviders(Togetherwecan:TheplantoimprovementalhealthandaddictionscareforNovaScotians,N.D.).AnSBIRknowledgeexchangeworkshopwasheldonSeptember30,2014,sponsoredbytheNovaScotiaDHWandattendedby37primarycarepractitioners,collegeandassociationrepresentatives,andpolicymakersfromacrosstheprovince.Inputfromthissessionsuggestedthatthefirststepistodevelopaflexiblemodelthat:

ü Reflectsthelocalcontext,ü Leversexistingprogramsasappropriate,ü Includesandintegratestoolsthatenableefficientandeffectivecollaborative

Practice,andü Isfinanciallysupportedbygovernment.

Participantsalsodeterminedthatthemodelshouldbedevelopedthroughacollaborative,consultativeprocessthatincludedtheparticipantsfromtheSeptembersessionandinputfromasmanyotherprimarycareprovidersaspossible.Finally,themodelshouldbeimplementedincrementallythroughdemonstrationsitestoensurethatappropriateadjustmentscouldbemadebeforerolloutacrosstheprovince.


3. EVIDENCEINSUPPORTOFSBIRThevastmajorityofSBIRevidencecomesfromtheuseofSBIRinprimarycaresettingstoaddressproblematicalcoholuse.InadditiontoCanada’s2007nationalalcoholstrategy(NationalAlcoholStrategyWorkingGroup)andCFPC’sandCCSA’sonlinetoolAlcoholScreening,BriefInterventionandReferral:HelpingPatientsReduceAlcohol-relatedRisksandHarms(2012),thePublicHealthAgencyofCanada’s2008four-levelframeworkforpreventingandaddressingfetalalcoholspectrumdisorder(Poole,Fetalalcoholspectrumdisorder(FASD)prevention:Canadianperspectives)alsosupportsuniversalimplementationofholisticapproachestoalcoholuseduringpregnancy.Despitetheavailableresourcesandevidence,therehasbeensignificantvariationintheuptakeofSBIRpractices(Giesbrecht,etal.,2013).NovaScotiawasamongthejurisdictionsthathadnottakenasystematicapproachtoimplementingSBIR.

Slowly,SBIRresearchisexpandingintootherareas,includingsubstanceusemorebroadlyandmentalhealth.ThechallengeisnottodemonstratetheeffectivenessofSBIR,whichhasalreadybeenestablishedbyalargebodyofresearch,buttodevelopimplementationpracticesandpoliciesthatmakeitviableforbusyprimarycaresettingstopracticeSBIR.

3.1 WhytheSBIRapproachisimportant

Evidencesupportsearlyidentificationforriskysubstanceuse,particularlyalcohol(Berger&Bradley,2015,Madrasetal.2009).Thebenefitofearlyinterventionisalsoconfirmedforlowtomoderatelevelsofdepression(Markoffetal.2005,AmericanCollegeofObstetricianGynecologists,2008).Usingvalidatedearlyscreeningtoolsforriskysubstanceuseanddepressionisalsoshowntobeeffectiveifappropriateinterventionscanbemadeinatimelymanner.Anumberofvalidatedscreeningtoolsalreadyexist.Effectiveandaffordableearlyinterventions,suchasMotivationalInterviewing(MI)-basedbriefinterventionsformoderaterisksubstanceuseandCognitiveBehaviouralTherapy(CBT)forlow-moderatelevelsofdepression,aresupportedbytheresearchliterature.

Primarycareteamshavethecapacityto:

a) educateallpatientsandidentifymentalhealthandsubstanceuseissuesearly,b) interveneearlyforpatientswithlowtomoderatementalhealthandsubstanceuseissues,c) referpatientswithsevereissuestospecializedservices,andd) supportandcoordinatecareforpatients—andtheirfamilies—duringandsubsequentto

theirperiodsofintensivementalhealthandsubstanceusetreatment.

DespitetheevidencesupportingtheuseofSBIRtoolsandprotocols,theiradoptioninprimarycaresettingsremainslow.Canadianphysiciansidentifyalackofknowledgeandtrainingabouttheeffectsofandtreatmentsforsubstanceuseduringpregnancyasabarriertoprovidingcare.Somephysiciansfeelrushedandarehesitanttoscreenpatientsforproblematicsubstanceuseandmentalhealthconcernsbecausetheyseemtobebeyondthescopeoftheirpractice(Wong,Ordean,&Kahan,2011).Primarycarephysicians,nursepractitioners,nurses,andotherhealthprovidersneedopportunitiesandresourcestocreatepracticalsolutions.


3.2 Whatwehavelearnedfromotherjurisdictions

Dr.DavidBrownhasbeenleadinganSBIRinitiativeinSaskatchewan(Brown,March2012).HehasdemonstratedthatSBIRcanbeimplementedinaprimarycaresetting,butrequirescollaboration,leadershipfrompractitioners,andastagedapproach.Amonglessonslearned,Dr.Brownrecommendsthatscreeningbedonewithhighlyefficientvalidatedtoolsinawaythatnormalizestheprocessandreducesstigma;screeningquestionsshouldbeself-completedtosavepractitioners’time;andtechnologiesareneededtofurtherincreaseefficiencyandreduceerror.Healsoemphasizedtheimportanceofpartnershipsbetweenprimarycareandotherserviceproviders.Finally,Dr.BrownassertsthatthemodeldevelopedinSaskatchewancouldbeexpandedandadaptedelsewhere.Additionally,Dr.BrownandDr.NancyPoole,DirectoroftheBCCentreofExcellenceforWomen'sHealth,havepartneredtoconductasystematicreviewofSBIRthroughagenderlens.ThisworkwillinformthefurtherdevelopmentandimplementationofSBIR.

TheNationalDrugandAlcoholResearchCentreattheUniversityofNewSouthWalesrecentlypublishedadocumentcalledSupportingPregnantWomenWhoUseAlcoholandOtherDrugs(Breen,Awbery,&Burns,2014),whichsupportsusingtheoreticalframeworkssimilartothoseusedinthisproject:relational,woman-centred,andtrauma-informedcare.Thereportacknowledgesthatpregnantwomenwhohaveproblematicalcoholordrugusehavedifferentneedsfromthegeneralpopulationofpregnantwomenandrequireextrasupporttoreduceharm;theyneedcomprehensiveassessment,care,andbriefinterventions;andthoseshouldbespecificallytailoredtoeachwoman’sneeds.

3.3 Focusonpregnantpatientsandnewmothers

3.3.1 Prevalenceofsubstanceuse

Basedonnationaldata,10.5%to17%ofwomensmokedinpregnancy,10.5%to14%consumedalcoholinpregnancy,and5%reportedusingillicitdrugsinpregnancy(PublicHealthAgencyofCanada,2009;Sauve&Dzakpasu,2008;Wong,Ordean,&Kahan,2011).However,giventhesystematicunderreportingofsubstanceuseandthestigmaattachedtosubstanceuseinpregnancy,theactualprevalenceratesareprobablyhigher(Finnegan,2013)(Ordean,Kahan,Graves,Abrahams,&Boyajian,2013).Therecontinuestobeconsiderablestigmaassociatedwithwomenwhoarepregnantormotheringandwhohavechallengeswithsubstances(Stone,2015).Thestigmaisperpetuatedbyacultureofblamingandalackofsympathy(Finnegan,2013),withafocusontheindividualresponsibilityofthewomantostopusingsubstancesinsteadofconsideringthemultiplefactorsthatinfluenceherchallengeswithsubstanceuse(Bell,Andrew,DiPietro,Chudley,Reynolds,&Racine,2016).Althoughtherecontinuetobelocal,national,andinternationalinitiativesfocusedonchangingknowledge,attitudes,andpractices(BritishColumbiaCentreofExcellenceforWomen'sHealth,N.D.)(Ordean,Kahan,Graves,Abrahams,&Boyajian,2013)(WorldHealthOrganization,2014)(NovaScotiaDepartmentofHealthPromotionandProtection,AddictionServicesAlcoholTaskGroup,2007),pregnantwomenwhousesubstancesmaynotaccessthecaretheyneedforfearofjudgmentanddiscrimination(NationalTreatmentStrategyWorkingGroup,2008)(Poole&Dell,2005).


3.3.2 Potentialmaternal,fetal,andnewborncomplications

Thereareknownnegativephysiologicaleffectsofalcoholandotherdrugexposureonthedevelopingfetus,pregnancyprogression,andmaternalhealth(JOGC,2010).Illicitdruguseduringpregnancyplacesthemotheratincreasedriskofavarietyofobstetricalcomplications,includingearlypregnancyloss,pre-eclampsia,andprematurelabour(Finnegan,2013).

3.3.3 FASD–Fetalalcoholspectrumdisorderandtheimportanceofscreening

FASDis“anumbrellaterm,whichdescribesarangeofeffectsthatcanoccurinsomeoneprenatallyexposedtoalcohol.Theseeffectscanincludelifelongphysical,mental,behaviouraldifficulties,andlearningdisabilities”(CanFASD)(Cook,etal.,2015).TheprevalenceofFASDinNovaScotiaisestimatedtobeoneoutofevery100children,withanannualcostofFASD-relatedservicesofmorethan64milliondollars(GaryRobertsandAssociates,2007-2008).

AuthorsofasurveystudyaimedatexploringtheuseofalcoholbypregnantwomeninNovaScotia(Carson,ElliottRose,&MacPherson,2013)foundthatalmostone-thirdofwomensurveyeddidnotdisclosetheiralcoholusetohealthcareproviders(HCPs).Iftheydiddisclose,theyoftenunderreportedtheamounttheyweredrinking.VeryfewwomenreportedthatHCPshadtalkedwiththemaboutdrinkingandbarrierstostopping.Overall,71%ofwomenperceivedtheydidnotgetanyeducationorsupportinrelationtousingalcoholinpregnancy.Thefindingssuggestthatpatientsneedtofeelsafertodisclosealcoholuseinpregnancy.

ArecentreviewofevidencecommissionedthroughtheNationalDrugandAlcoholResearchCentreinAustralia(Breen,Awbery,&Burns,2014)foundthatwomenwhohaveriskydrinkingpatternspriortoconceptionarelikelytocontinuethosepatternsintotheirpregnanciesandthatbeingpregnant,orthepossibilityofbeingpregnant,maymotivatewomentochangetheiralcoholordruguse.CurrentCanadianbestpracticeguidelinesrecommendthatcliniciansprovideasafespaceforallwomentodisclosealcoholandothersubstanceusewithroutinescreeningaspartofhealthservices(JOGC,2010)(Wong,Ordean,&Kahan,2011).

3.3.4 Prevalenceofmentalhealthconcerns

Asmanyastwo-thirdsofwomenwithsubstanceuseproblemsalsohavementalhealthproblems(Finnegan,2013,p.26).Inaddition,awomanisatthehighestriskinherlifetimeofdevelopinganewmentalillnessinthefirstyearafterababyisborn.“Atleast15percentofnewmothersexperiencesignificantpostpartummooddisordersandmanymorereportimportantdifficultiesincopingandadjusting”(MacDonald&Flynn,2012,p.vi).Womenandtheirfamiliesareoftensurprisedbythementalhealthchallengesthatcancomewithpregnancyandbirth,sincemostwomenhavenoprevioushistoryofmentalillness.Halfofallwomenwithpost-partummooddisordersneverseektreatment(MacDonald&Flynn,2012).Almost8%ofparticipantsintheMaternityExperiencesSurvey(PublicHealthAgencyofCanada,2009)reporteddepressivesymptoms,with15.5%statingthattheywerediagnosedwithdepressionortreatedwithanti-depressantspriortopregnancy.13%statedtheyhadlittleornosupportavailablewhentheywerepregnant,andthosewomenwhoexperiencedphysicalorsexualabuseweremorelikelytoreportstress,depression,andhavinglimitedornosocialsupport.

HCPscanmakeasubstantialdifferencetothehealthofpatientsandtheirbabiesbyidentifyingandsupportingpatientswhoexperiencementalhealthissues,orusealcoholorotherdrugsduringpregnancy.Evidenceshowsthatwell-coordinatedandcomprehensivesupportwithearlyaccessto


antenatalcareandspecializedmentalhealthandsubstanceusetreatmentcanreduceharmandimproveoutcomesforpregnantpatientswhohaveproblematicsubstanceuseand/ormentalhealthissues,andtheirbabies(NationalDrugandAlcoholResearchCentre,UNSWAustralia,2015).AccesstocarecanbeimprovedwhenHCPsaskpregnantpatientsaboutalcoholanddruguseandknowhowtoreferandcoordinatetheircare.

ItisimportantthatHCPsnotmakeassumptionsaboutthe“type”ofpatientswhomaybeusingalcoholorothersubstances,orexperiencingmentalhealthissuesduringpregnancyorfollowingthebirthofababy.Alcoholanddrugsareusedbypeopleacrossthepopulation.Allpatientsofchildbearingageshouldbeaskedaboutalcohol,tobacco,andotherdrugsduringhealthcareencounters.Pregnancyisoftenatimewhenpatientsareaccessinghealthcareservicesonaregularbasisandthereisanopportunitytobuildtrustingrelationships.Disclosuremayoccurasrapportisbuiltorpatternsofusemaychangeovertime,soit’simportantforpatientstobeaskedaboutsubstanceuseandmentalhealthateveryhealthcarevisit(NationalDrugandAlcoholResearchCentre,UNSWAustralia,2015).

4. ABOUTTHESBIRDEMONSTRATIONPROJECTTheprojectisco-ledbyWandaMcDonaldandDr.AnnetteElliotRose.Duringtheproject,WandawasManager,MentalHealth,Children’sServicesandAddictionsBranch,NovaScotiaDepartmentofHealthandWellness.AnnettewasaPerinatalNurseConsultantwiththeNovaScotiaReproductiveCareProgram.Aprojectcoordinator,ErinCasey,joinedtheteaminMarch2015andtheevaluator,LisaJacobs,cameonboardinJune2015.

ThepurposeoftheProjectwastoformallyintroduceandsupportanSBIRinitiativeaimedataddressingsubstanceuseandmentalhealthforpregnantpatientsandnewmothersinacollaborativeprimarycaresetting.Theobjectivesoftheprojectincluded:

Ø TouseSBIRtoidentifyproblematicsubstanceuseandmentalhealthconcernsinpregnancyandnewmotherhood

Ø Toimproveawarenessandknowledgeamongprimarycareprovidersofperinatalsubstanceuseandmentalhealthconcerns

Ø Tofacilitateevidence-based,empathetic,andcomprehensivesolutionsforproblematicsubstanceuseandmentalhealthissuesusingrelationalcareandtrauma-informedcarepractices

Ø ToconnectpregnantpatientsandnewmotherswiththesupportsandservicestheyneedØ Tounderstandwhattoolsandsupportsarerequiredinprimarycaresettingsto

facilitateuptakeofSBIRbyhealthcareproviders

Thelastobjective,tounderstandwhathealthcareprovidersneedtoadopttheprincipalsoftheSBIRapproach,wasthemostsignificantcomponent.Developmentalevaluationwasusedtodeepentheunderstandingofwhat,ifanything,primarycarestafffindhelpfulinsupportingtheiruptakeofSBIR.Itisthehopeoftheprojectteamthatfindingsfromthisprojectwillinformscale-upofSBIRinNovaScotia.


4.1 GuidingprinciplesoftheSBIRdemonstrationproject

4.1.1 Relationalcare

Therelationalmodelproposesthatthebestenvironmentforemotionalgrowthandchangeiswithinthecontextofoneormoremutual,empathic,authenticrelationships.Suchrelationshipsallowindividualstobetterunderstandthemselvesandothers,leadtothedesireformoreconnection,andcreateafeelingofexcitementandzestthatstimulatespeopletoaction(Markoff,Finkelstein,Kammerer,Kreiner,&Prost,2005,p.228).Literaturesupportsarelationalmodelforthepreventionandtreatmentofsubstanceuseandmentalhealthissuesinwomen.Itemphasizestheimportanceofencompassingwomen'srelationalhistoriesandrelationshipswithinthetreatmentenvironment,includingbuildinghealthyconnectionsandaddressingdisconnectionssuchasviolenceandtrauma(McQueen&Murphy-Oikonen,2016;Kramlich&Kronk,2015).

4.1.2 Trauma-informedcare(TIC)

TICfocusesonsafety,trust,choice,collaboration,andconnection.Theaimistofocusonstrengthsandskillbuildingandtounderstandtheuniquecontextsofpatients’lives,histories,andthepresentchallengesthatinfluencetheirexperiences.UnderstandingtherolethatpastorcurrenttraumamayplayinthelifeofapregnantwomanornewmotheriskeytobuildingthetrustrequiredfortheSBIRapproachtoworkmosteffectively.Atrauma-informedapproachbeginswithbuildingawarenessamongstaffandclientsofthecommonnessoftraumaexperiences;howtheimpactoftraumacanbecentraltoone’sdevelopment;thewiderangeofadaptationspeoplemaketocopeandsurviveaftertrauma;andtherelationshipoftraumawithsubstanceuse,physicalhealth,andmentalhealthconcerns(Trauma-informedpracticeguide,2013).

4.1.3 Patient(woman)andfamilycentredcare

“Patientandfamilycentredcareisanapproachtoplanning,deliveryandevaluationofhealthcarethatisgroundedinmutuallybeneficialpartnershipsamongpatients,familiesandhealthcareproviders”(Johnson,etal.,2008).Thisincludesrespectforpatients’values,expertise,andneeds;improvedcommunication,education,anduseofinformationtechnology;afocusontheemotionalaswellasthephysicalexperiencesofpatients;timeforpatientstoexpresstheirneedsandbeheard;fairnessinprovidingcareandattention;andsmoothcaretransitionsaimedatprovidingcontinuity(Johnson,etal.,2008).HCPsneedtofocusonhealthcareasanintegratedservicedesignedtorespondtopeople’sneeds.Thisshouldbeprovidedinteam-basedsettings,withadequatetimetoaddresscomplexneeds,wherepeoplefeelengagedandactiveintheirowncare(Silow-Carroll,Alteras&Stepnick,2006;Sidani,2008;Spragins&Lorenzetti,2008;Lewis,2009).

4.1.4 Collaborativecare

NovaScotiaisshiftingfromatraditionalpatient-doctorsettingtoCollaborativeInterdisciplinaryCareTeams.Byworkingtogether,theseprofessionalscanprovidetimely,appropriate,responsive,comprehensivecarethatpromotesgoodhealthandenhancesqualityoflife.(Formoreinformation,visithttp://novascotia.ca/dhw/collaborative-care-teams.)


4.2 Partnersandstakeholders

4.2.1 DalhousieFamilyMedicinecollaborativecareclinics

TheSBIRteampartneredwithDalhousieUniversityFamilyMedicineattwoHalifaxcollaborativecaresites:theSpryfieldandMumfordFamilyMedicineClinics.Theseareteachingandreferralclinics,wheremedicalstudentsandresidentsseepatientsandareobservedbystaffphysiciansathalf-dayprenatalclinicseachweek.Therearethreeprenatalphysiciansateachclinic,twonursesperclinic,andaprenataleducator.Intotal,theclinicscareforabout150prenatalpatientsperyear.Intheclinic,theprenataleducatorusesamodifiedCenteringPregnancy1approachwithpatientsastheywaitfortheirprenatalappointments.Thenursestypicallycompletetheinitialassessments,andthenthewomanisseenbytheresidentwithreviewofthecareencounterbythestaffphysician.Thefirstprenatalappointmentisusuallyhalfanhourandsubsequentappointmentsare15minutes.

AftertheSBIRtrainingwascompleted,HCPsineachclinicbeganusingSBIRwithpatients,andwereableto“dummybill”eachSBIRencounterinPractimax,theelectronichealthrecord(EHR)system,inordertotrackit.Refreshersessionsandperiodiccheck-inswithHCPshaveoccurredthroughouttheproject.

4.2.2 BehaviourChangeInstitute

TheSBIRProjectpartneredwithhealthpsychologistDr.MichaelVallistodevelopanddelivertraininginmotivationalinterviewing(MI)forparticipatingphysicians,nurses,andmedicalresidents.Thepre-andpost-nataleducatorfromthelocalFamilyResourceCentre(FRC)wasalsotrained.TheworkofDr.VallisandhiscolleaguesattheBehaviourChangeInstitute(http://www.behaviourchangeinstitute.ca)wasadaptedtocreatetoolsforHCPs:twolong-formalgorithms,oneformentalhealth(MH)andoneforsubstanceuse(SU),andoneshort-form“bookmark”addressingbothMHandSU.PleaseseeappendicesAandB.4.2.3 MentalHealthandAddictionServicesintheNovaScotiaHealthAuthority

Issuesofmentalhealthandaddictionoftenoccurtogether.TheNovaScotiaHealthAuthority’s(NSHA)AddictionandMentalHealthProgramistakingacollaborativeapproachtoimprovingcareforpeoplelivingwithconcurrentdisorders.From20to80percentofclientsinaddictionsandmentalhealthhaveconcurrentdisorders,dependingonthesetting.

4.2.4 ChebuctoFamilyCentre

AsthefamilyresourcecentreservingSpryfieldandthesurroundingarea,themissionofChebuctoFamilyCentreisto“nurtureandenhancethequalityoflifeoffamiliesthroughthedeliveryofcommunity-basedprogramsandservices.”Allprogramsandservicesarefreeandavailabletoanyoneinthecommunity.TrenaSlaunwhite-Gallant,thepre-andpost-nataleducatoronstaffattheFRC,doesextensiveoutreachintothecommunity,andoffersindividualandgroupsupporttopregnantpeopleandnewmothersattheFRCandaspartoftheweeklypre-natalclinicsatbothSpryfieldandMumford.ShealsositsontheSBIRSteeringCommittee.

1TheCenteringPregnancymodelwascreatedintheUnitedStatesasaformofgroupprenatalcarewiththreecomponents:(1)physicalassessment(theprenatalvisit),(2)education,and(3)peersupport (https://www.centeringhealthcare.org/what-we-do/centering-pregnancy).


4.2.5 SteeringCommitteeTheSBIRProjectwasguidedbyamulti-disciplinaryadvisorycommittee,whichmeteveryfewweeks.Itconsistedoftheprojectleads,coordinator,evaluator,andrepresentativesfrommentalhealthandaddictions,publichealth,theFRC,clinicstaff,acutecare,andthecommunity.AcompletelistoftheSteeringCommitteemembersisavailableontheAcknowledgementspageofthisreport.

4.3 HowtheSBIRprojectworked

4.3.1 Assetmapping,research,relationshipbuilding,andpreparation

ThefirststagesoftheprojectinvolvedreviewingthelatestliteratureaboutSBIRinCanada,theUnitedStates,andinotherjurisdictionssuchasAustralia.TheprojectteamwantedtoensurebeforetrainingHCPsandimplementingSBIRintheclinicsthattherewereadequatecommunity,medical,andotherresourcestosupportbothbriefinterventionsandreferralstotreatment.Theyalsowantedtoallayconcernsabouthowthisprojectwouldimpacttheresourcesavailableintheclinics.ThefocusofSBIRisonthelowtomoderateriskpatientwithmentalhealthand/orsubstanceuseissues.Therefore,theintentofthetrainingistobuildtheconfidenceandcompetenceofprimarycareproviderstomanagelowtomoderateriskcasesintheprimarycaresetting.Inthisway,itisanticipatedthatSBIRcouldhelpoptimizereferralstospecializedservices.Thecoordinatorundertookathoroughmappingofthelocalassets,bothwithinthelocalcliniccommunitiesandacrossgreaterHalifax.Theassetlistincludedgovernmentandcommunityservices,not-for-profitorganizations,religiousinstitutions,schools,andotherservices,fromfoodbankstoBoysandGirlsClubstoCommunityHealthTeams.Whilethesystemisnotperfect,whatemergedwasafairlyrobuststructureofsupportsforindividualsandfamiliesdealingwitharangeofissuesincludingpoverty,addictions,andmentalhealth.TheProjectleadsandcoordinatoralsometwithmanydifferentstakeholderstoensuretheyknewaboutthework.

4.3.2 Selectingandestablishingthesetting

TheDalhousieFamilyMedicineclinicsinvolvedintheProjectrunonacollaborativecaremodel,whichmeanstheHCPswhoworktheredonotoperateonafee-for-servicebasis;physiciansaresalaried.Despitehavingsomewhatmorefreedomfrombillingforeachindividualhealthcareservice,theywerestillverylimitedbythetimeconstraintsofabusymedicalpractice.IntheSpryfieldFamilyMedicineClinic,mentalhealth,addictions,communityhealthteamwellnessnavigators,ayoungmothers’mentalhealthprogram,andotherservicesareco-located.TheMumfordFamilyMedicineClinichassomeco-locatedservices,butisnotaswellresourced.Bothclinicsemployamodified“CenteringPregnancy”modelandallpregnantpatientsandnewmothersspendtimewithapre-andpost-nataleducatorfromthelocalfamilyresourcecentreandwithstaffnurses.TheProjectteammetmanytimeswiththeleadershipoftheclinicstoestablishatrustingrelationshipbeforeimplementingSBIRtrainingandfollowupmonitoring.

4.3.3 Focusgroups

TheProjectteamconductedafocusgroupattheChebuctoFamilyCentrewithpregnantwomenandnewmotherstoinformthedevelopmentoftheSBIRapproachandmaterials.Somehighlightsofthefocusgroupincluded:


• MostparticipantssaidthatwhiletheyhadbeenaskedquestionsaboutSUandMHbytheirHCPs,thequestionswereusuallyclosedended(requiringayesornoanswer),andwerenotrepeatedatsubsequentappointments.

• Manyparticipantsfeltphysiciansweremorefocusedonthehealthofthebabythanthatofthemother,andquestionsaboutmentalhealthoftenwerenotvigorouslypursueduntilafterthebabywasborn.

• AllagreedthattrustwascriticaltofeelingcomfortabletalkingaboutSUandMHwithanHCP.Manynotedfeelingrushedinthedoctor’soffice.

• Whilemostparticipantswouldbewillingtofilloutaquestionnairepriortoseeingthedoctor,open-endedquestionsandpromptsarebest.

• ManyparticipantsinthegroupnotedhowimportantitisnottofeeljudgedbytheirHCPwhendisclosingsubstanceuse,mentalhealthissues,ortrauma.Theyalsosaidthatifasensitivetopicarises,theHCPshouldbepreparedtorespond.

4.3.4 Toolsandtraining

ThedevelopmentofboththeSBIRtoolsandtrainingfollowedaniterativeprocessofdeveloping,drafting,training,testing,gatheringfeedback,andre-developing.TheinitialtooldevelopmentbytheProjectteamwasasetoftwo“algorithms”outliningabasicprocessfortalkingwithpregnantpatientsandnewmothersaboutmentalhealthandsubstanceuse(AppendixA).Eachtoolwasprintedontwo-sidedlegal-sizedpaperandlaminated.ThedevelopmentofthetoolwasguidedbythemotivationalinterviewingprinciplesofDr.MichaelVallisandhisteamattheBehaviourChangeInstitute.Atthesametime,Dr.Valliswascreatingatwo-hourtrainingsessionforHCPstohelpthemlearnthebasicsofMIforSBIR.

Apre-trainingpackagewascreatedforallparticipants,andincludedthefollowing:

§ AshortonlinesurveyforHCPstocomplete,togaugetheirexperiencewithMI§ SBIRProjectOverview§ DiscussionGuide1–TRAUMA-INFORMEDAPPROACHES:AnIntroductionandDiscussion

GuideforHealthandSocialServiceProviders§ Video:WomenofSubstance:www.facebook.com/WomenofSubstanceNovaScotia§ Video:OverviewofMotivationalInterviewingSkills:

http://www.behaviourchangeinstitute.ca/Motivational_Interviewing.html§ Canada’sLow-RiskAlcoholDrinkingGuidelines:

http://www.ccsa.ca/Resource%20Library/2012-Canada-Low-Risk-Alcohol-Drinking-Guidelines-Brochure-en.pdf

Additionalresourcesinthepackageincluded:

§ AlcoholScreening,BriefInterventionandReferral:http://sbir-diba.ca/§ Mothers’MentalHealthToolkit:AResourcefortheCommunity:

http://www.iwk.nshealth.ca/themes/iwkhc/downloads/mmh-toolkit.pdf§ Trauma-InformedPracticeGuide:http://bccewh.bc.ca/wp-

content/uploads/2012/05/2013_TIP-Guide.pdf§ TraumaMatters:GuidelinesforTrauma-InformedPracticesinWomen’sSubstanceUse

Services,http://www.jeantweed.com/LinkClick.aspx?fileticket=3-jaLM6hb8Y%3d&tabid=107&mid=514jaLM6hb8Y%3d&tabid=107&mid=514


§ LicitandIllicitDrugUseDuringPregnancy:Maternal,NeonatalandEarlyChildhoodConsequences:http://www.ccsa.ca/Resource%20Library/CCSA-Drug-Use-during-Pregnancy-Report-2013-en.pdf

§ TheNationalAlcoholStrategy:http://www.ccsa.ca/Resource%20Library/ccsa-023876-2007.pdf

§ TheSocietyofObstetriciansandGynaecologistsofCanadaClinicalPracticeGuidelinesforsubstanceuseinpregnancy:http://sogc.org/guidelines/substance-use-in-pregnancy/andhttp://sogc.org/wp-content/uploads/2013/01/gui245CPG1008E.pdf

§ TogetherWeCan:TheplantoimprovementalhealthandaddictionscareforNovaScotians:http://novascotia.ca/dhw/mental-health/reports/Mental-Health-and-Addictions-Strategy-Together-We-Can.pdf

§ Trauma-InformedPracticeinNovaScotia–AWebinarSeries:http://bccewh.bc.ca/newsevents/webinars/

Dr.Vallisdeliveredthetrainingsessionsonthefollowingdates:

• Tuesday,July14thfrom6pmto8pm–SpryfieldClinic• Thursday,July20thfrom6pmto8pm–MumfordBoardroom• Tuesday,August18thfrom3pmto5pm–SpryfieldClinic• Thursday,August13th–medicalresidentstrained

Aftereachsession,participantsprovidedfeedbackusinganevaluationform.Eachsessionyieldedimportantinputtobeincorporatedintothetoolsandtraining.Basedonfeedbackfromeachgroup,adjustmentsweremadetothealgorithms,andashort-form“bookmark”(AppendixB)versionwascreated,suitableforputtinginapocket.Finally,abrochureforpatientsentitledConversationsaboutyourcare(AppendixC)wascreatedfornursestogivepatientstostarttheSBIRdiscussion.Intotal,approximately15staffHCPsand15medicalresidentsweretrained.

OnceSBIRwasupandrunningintheclinics,[email protected],andsenttimelyandinterestingSBIRtipsandresourcestotheparticipatingHCPsonaweeklybasis.

Inthefall,anoptionalfollow-upsessionwasheldtoextendthelearningaboutSBIRandansweranyquestionstheparticipatingHCPsmighthave.Althoughaninvitationwasextendedtoalltheparticipants,onlyabout20%attendedthissession.

5. PROJECTEVALUATION

5.1 DevelopmentalevaluationThisSBIRprojectwasevaluatedusingadevelopmentalevaluation(DE)approach(Patton,2011).DEsupportsinnovationandlearningincomplexandemergentsituationsandwhentheoptimumapproachandendstatearenotknownorknowable.Itiswellsuitedforprojectsthatareinastateofcontinuousdevelopmentandadaptation.Unlikeprocessevaluations,whichfocusonprogramimprovement,andoutcomeevaluations,whichfocusonprogrameffectiveness,DEfocusesoncontinuouslearninganddevelopment.Itdoesthisbyintegratingevaluativethinkingwithprogramdesignincontextswherethepathwaystochangearenotpredeterminedandareoftennon-linear.Assystemsshift,programlogictakesabackseattoactingontimelydataanalysistoinformongoing


decision-makingandadaptations(Dozois,Langlois,&Blanchet-Cohen,2010).Ongoingandrapiddatacollection,analysis,andcommunicationsallowprogramstakeholderstoberesponsivetonewknowledgeandmakechangessothattheproject,program,orinitiativeevolves.DEtendstobehighlyparticipatoryandfacilitatesadaptationsthatareownedbystakeholdersandstaff.

UsingDEforthisprojectwasappropriateforanumberofreasons.First,thereissubstantialevidencetosupporttheuseSBIRincombinationwithMIasamethodtoencourageandsupportbehaviourchange.Therewaslittleevidenceandbestpractices,however,forhowtointegrateSBIR,MI,andwomanandfamilycentred,trauma-informedmodelsofcarebyprimaryhealthcareproviders(PHCPs)tosupportpregnantpatientsandnewmothersforSUandMH.Therewasalsonopre-existingmodelorapproachinCanadaforusewiththispopulation–itwouldhavetobedeveloped(Dozois,Langlois,&Blanchet-Cohen,2010).

Second,theprojectteamknewthattheywouldhavetodevelopanSBIRapproachthatwouldbeusedbyPHCPsinNovaScotia.Theywereawareofsystem-levelissues,suchastheshort15-minuteprenatalappointmenttimeandthefee-for-servicemodel,thatwouldsignificantlyimpactwhetherandhowtheapproachwouldbeused.Thesesystem-levelfactorswouldshapewhattheSBIRapproachwouldbe.

5.2 EvaluationquestionsFiveprimaryevaluationquestionsshapedthisproject.ThefirsttwoquestionsguidedthedevelopmentoftheSBIRapproachandSBIRtraining.

1. Whatisthebestevidence-basedSBIRapproachthatPHCPscanuseinclinicalprimarycarepracticesettingstosupportthehealthofpregnantpatientsandnewmothers?

2. HowmuchtrainingandwhatkindoftrainingdoPHCPsneedinordertofeelcompetentinusingSBIR?

ThenextquestionguidedthemonitoringofSBIRuptake.

3. ArePHCPsusingtheSBIRapproach?

ThelasttwoquestionsguidedongoingdevelopmentoftheSBIRapproachwithafocusonunderstandingSBIRusewithintheprimarycarecontext.

4. WhataretheexperiencesofPHCPsusingtheSBIRapproach?5. Whatarethedrivingfactors(barriers/facilitators)behindusingornotusingtheSBIR

approach?

5.3 Methodology

Developmentalevaluationisdatadrivenandresultsoriented.Theevaluatorworkedwithmembersoftheprojectteamtoidentifydatacollectionandanalysispointsthatwouldservetodeveloptheproject.AppendixDoutlinesthedatacollectionpointsandpurpose.ThedataprovidedongoingopportunitiestoinformcontinuouslearningandSBIRapproachmodificationsbasedonhowPHCPswererespondingtotheproposedSBIRapproach.


Forthekeyinformantinterviews,everyPHCP(supervisingphysicians,nurses,andmedicalresidents)wereinvitedtobeinterviewedbytheevaluator.Severalinvitationsweresentandtheclinicaldirectorsalsoverballyencouragedparticipation.Intheend,theevaluatorspokewithsixphysicians,twonurses,andtworesidents.

Eachofthetwoclinicsoffersaprenatalcliniconehalfdayaweekthatlastsaboutthreehours.Thefirstprenatalvisitis30to45minutesandeachsubsequentappointmentis15minutes.Usually,nineto15patientsareseen,butthenumbercangoashighas20.

Patientsarefirstseenbyaregisterednurse(RN),whoconductsurinetestsandmeasuresthepatient’sbloodpressureandweight.Thepatientsthenstayinaprenatalwaitingareauntiltheyareseenbyaresident.Duringthatwaitingtime,thepre-andpost-nataleducatorfromthelocalFRCisavailabletotalkaboutarangeofwellness-relatedissues,andthepatientstalkwithandsupporteachother.Eachpatientisseenbyafirst-orsecond-yearfamilymedicineresident.Residentsaredirectlysupervisedbyfamilyphysicians,whoobservefromaseparateviewingroomandoftenjointheresidentandpatientattheendoftheappointment.

5.4 ContextandlimitationsContext.Thetwositesforthisprojectwereteachingclinicsthatusedacollaborativecaremodel.TheclinicswereagoodchoiceforinitialdevelopmentoftheSBIRapproachbecausestaffmembersweremotivatedtodevelopbestpracticesthatcouldbeusedbyfuturefamilyphysicians.Teachingclinicsareexpectedtomodelforresidentshowtodeveloppositivephysician/patientrelationships.Asonephysiciansaid,“Wehavetobereally,reallygoodatthis.”UsingbestpracticesisexpectedattheseclinicsandthePHCPshaveopportunitiestodevelop,practice,andmodelthemonadailybasis.MostPHCPsdonotpracticeinthiskindofalearning-intensiveorfocusedenvironment.Inaddition,bothclinicshadaccesstonursingandonsiteorrelativelyeasilyaccessedmentalhealthandaddictionstreatmentservices,whichisnottypicalofmostprimaryhealthcaresettings.

Thephysiciansatthetwositesaresalariedandsalariedphysiciansmaynotexperiencetimeconstraintstothesamedegreeasthosewhopracticeasfee-for-service.Thislimitationistemperedsomewhatbythefactthatthetwoclinicsareexpectedtoseeasmanypatientsaswouldbeseenbyfee-for-servicepractices(shadowbilling)soservicedemandswouldbesimilar.

PatientsdidnotseethesamePHCPeverytimetheycametotheclinic.Physicianssuperviseresidentsonceeverythreeweeksandresidentschangedusuallyeveryfourmonths.ThissetupisnottypicalofmostprimaryhealthcaresettingsanditlikelyimpactedhowpatientsexperiencedtheSBIRapproach(i.e.SBIRquestionsbeingaskedbydifferenthealthcareprovidersmayinterruptpositiverelationshipbuilding,anexpectedoutcomeofusingtheSBIRapproach).SomePHCPsnotedthatitwasawkwardwhentheyusedSBIRandthenfoundoutthatthepatienthadalreadybeenaskedbyanotherPHCPduringanearliervisit.ThismayhavediscouragedsomePHCPsfromtryingSBIR.

Finally,residents,notphysicians,weretheprimaryusersofSBIRinthisprojectandresidentsdon’thavethebenefitofyearsofexperienceworkingwithpatients.Severalphysiciansnotedthatresidentsareoften“overwhelmed”byeverythingtheyneedtolearnaboutthemedical/physicalcareofpregnantpatients.TheprojecthaslimitedfeedbackfromphysicianswhodirectlyandactivelyusedtheSBIRapproachthemselves.


Thespecialcircumstancesatthetwoclinicslimithowfarthefindingscanbegeneralizedtootherprimaryhealthcaresettings.PilotinganSBIRapproachinmoretypicalhealthcaresettingsinNovaScotiaisanobviousnextsteptoarriveataclearerpictureofwhatmightwork.Thechallengeforthisprojectistoextractthelessonslearnedwhilekeepinginmindtheclinics’uniquecontext.

Limitations.Adevelopmentalevaluationfocusesoncontinuousadaptationandlearning.Nevertheless,somelimitationsregardingdatasourcesandqualityareimportanttonote.

ThereisnodataabouthowtheSBIRapproachwasexperiencedbypatients.ThefocusatthisstagewasonlyondevelopinganapproachthatmightbeusedbyPHCPs.Inaddition,aculturallenswasnotappliedtothisSBIRapproach;wedonotknowifthismodelwouldbeeffectivewithpatientsfromdiversebackgrounds.Theprojectteamrecognizesthatthemodelshouldnotonlybeprovider-driven.Inputfromadiverserangeofpatientsiscriticalforitsultimatesuccess.

Practimaxisanelectronicmedicalrecordandclinicmanagementsoftwareusedbythetwoclinics.ThedatafromthissystemgivesonlyanindicationofwhetherornotSBIRwasusedbyPHCPsandifitwasusedmorethanoncewiththesamepatient.Otherthanfornurses,itdidnotserveasareliablerecordofhowmanytimesSBIRwasusedbyresidentsorphysicians,mainlybecauseresidentshadtocodeundertheirsupervisingphysician,whorotatedandwhowouldalsohavecodedtheirownSBIRuse.AresidentcouldhaveusedSBIR40times,butitmayhavebeencodedunderthreedifferentsupervisingphysicians.Residentsandphysiciansalsoreportedthattheydidn’talwayscodetheirSBIRuse.

Thereissomesecond-handreportingthattheSBIRapproachwasusedbyPHCPsmainlywhentheyfelttheirpatientswereatriskofSUandMH.Thisdefeatsthepurposeoftheapproach,whichistoscreenallpatientswhoarepregnantorhaverecentlygivenbirth,touseitmorethanonce,andtouseMItechniquestosupportdisclosureandbehaviourchange.Thisinformationcouldnotbevalidatedthroughtheinterviewprocess.

Finally,theevaluationdesigndidnotaddressanyissuesrelatedtofidelitywiththeSBIRapproachpresentedinthetrainingsessions.FidelityissuescanbeaddressedonceamoreclearlydefinedSBIRapproachisdevelopedandapplied.

5.5 Findings

TheemphasisinthisevaluationwasondevelopinganSBIRapproachthatwouldbeusedinprimarycaresettings.Thissectionpresentsthefindingsfrom10interviewsconductedwithPHCPswhoparticipatedintheproject.Thefindingswereanalyzedbasedonfourquestions:

1. Howwas“SBIR”understoodbyPHCPsatthetwosites?Didtheyuseit,andifso,towhatextent?

2. TowhatextentdidPHCPsseevalueinpromotingandusingtheSBIRapproachwithpregnantpatientsandnewmothers?

3. Whatarethecriticalcontextissuesthatemergedfromtheprojectthatneedtobeconsideredmovingforward?

4. Basedonthisproject,whatshouldSBIRtraininglooklikemovingforward?WhatarethekeyresourcesneededtosupporttrainingandSBIRuse?


Question1:Howwas“SBIR”understoodbyPHCPsatthetwosites?Didtheyuseit,andifso,towhatextent?

UnderstandingSBIR.RespondentswereaskedtodescribehowtheydefinedSBIRasintendedbythisproject.AllPHCPsvieweditasabriefscreeningtoolthatwasdesignedtoidentifypotentialsubstanceuseandmentalhealthissues.TheyunderstoodthatMItechniquesareusedtoassessreadinessforandsupportbehaviourchangeanditmayinvolvemakingreferralstoothersupports.

OtherdescriptorsusedforSBIRwere:

• standardizesthediscussionofsubstanceuseandmentalhealththroughoutthecourseofapregnancyandgeneratesgreaterawarenessofhowthesecanimpactapregnancy

• communicatestoawomanthatherPHCPsareinterestedinhermentalhealth,aswellasherphysicalhealth

• opensupspacetohavemeaningfulconversationsthatarenon-judgmentalandnon-confrontational

• helpsPHCPsask“uncomfortable”questionsortalkabout“uncomfortable”issues.

Noneofthekeyinformantsmentionedthatthisapproachwasrootedinarelationalandtrauma-informedunderstandingofpregnantpatients’experienceswithsubstanceuseand/ormentalhealthproblems.Thismaypointtoaneedforgreateremphasisintrainingonwhythisapproachwasdeveloped.

ItisworthnotingthatallbutonePHCPsawSBIRassomethingthatwasrelativelydistinctfromothertasksthatneededtobecompletedwithintheprenatalappointment.ThisunderstandingoftheSBIRapproachisdifferentfromwhatthetrainerandseveralmembersoftheAdvisoryCommitteeviewitas,anapproachthatcanbeintegratedintogeneralpractice.

UsingSBIR.TheintentwasforPHCPstofollowtheSBIRsteps–Screening,BriefIntervention,andthenReferralasneeded–witheachpatientrepeatedly.ThealgorithmwasdesignedtobeapracticalguidetohelpcareprovidersgetusedtohavinganSBIRconversation.Asproviders’comfortlevelsincreased,itwasanticipatedthattheywouldrelylessontheguideandincorporatetheSBIRapproachnaturallyintotheappointment.

Basedonthecodingandinterviewdata,therewasavariablerateofuptakeofSBIR.SomePHCPsusedtheapproachupwardsof50times,consistentlyandmultipletimeswiththesamepatient.Othersreportedusingitonlyafewtimesformally(sixorfewertimes)and/ormodifyingitandnotcoding.SomephysiciansreportedthattheyobservedresidentsusingSBIRbutdidnotuseitthemselves,andsomeneitherusedSBIRnorobserveditsuse.

Basedontheinterviews,itseemsthatSBIRwasusedbysomePHCPsformally(goingthrougheachstepusingthealgorithm)whileothersmodifiedtheapproachtosuittheirownstyle.Atleasttworespondentssaidtheyusedthealgorithmoftenandwentthrougheachstepasneeded.Severalsaidthattheyusedthealgorithmformallyatfirstandlesssoastheircomfortlevelsincreased.TwoPHCPssaidtheyusedtheformalalgorithmonceortwiceandthenuseda“modified”SBIR,whichtothemmeanttheyscreenedanddidbriefinterventionandreferralwiththeirpatientsbutdidnotfollowthealgorithmsequence.OnePHCPdescribeshowsheusedSBIRasfollows:

“[T]hefirsttimeIsawherandshetoldmeaboutit[alcoholuse],IwentthroughtheguidethatIwasgiven,actuallyaskingthequestions.ButfromthereoninIhavejustusedmoreofasocialcheckin….[T]hisparticularladyisn’tdrinkinganymoreandshe’sfeelinggoodaboutit.Sothe


lastvisitshewasin,Italkedabout,‘Sonowwhathappensifthebaby’sbornandthebaby’scryingandthebaby’sreallycrankyandyou’resuperfrustrated,what’syourplan?Likeifyoualwaysrevertedtoalcoholinthepastandyou’retryingtostayoffofit,doyouhaveaplanastowhatyou’regoingtodo?’It’s[SBIR]justkindofallowedustotalkaboutwhat’sgoingtohappenafterthebaby’sborn.”

WelearnedthatinoneclinicthepracticewasfornursestogivepatientstheSBIRbrochuretoinformthemabouttheproject.Nursesencouragedpatientstoreadthebrochureandexplainedthattheywouldfollowupatthenextprenatalappointment.Atthenextappointment,theydidSBIRwiththepatient.Ifanissuewasraised,theymadeapointofcommunicatingthistotheresident/supervisingphysiciansothattheywouldknowtofollowup.It’snotclearifSBIRwasn’twidelyusedatthisclinicbecausenursesweredoingSBIRwithpatientsbeforehand.

AllrespondentswhousedSBIRsaidthatthemajorityofthepatientstheyuseditwithdidnotscreenforanyMHorSUissues.SeveralexperiencedpractitionerssaidthattheBriefInterventionpartwasdifficult–patientswould“shutdown”anditwasdifficultto“rollwithresistance”.

Question2:TowhatextentdidPHCPsseevalueinpromotingandusingtheSBIRapproachwithpregnantpatientsandnewmothers?

AllofthePHCPsinterviewedsaidthattherewassignificantvalueinusinganSBIRapproachinprimarycarepractice,evenforthosewhosaidtheyonlyusedSBIRafewtimesornotatall.

PHCPswhousedSBIRfoundithelpedscreenMHandSUissuesthatareonthelowerendoftheacuityscale,whichisthepopulationtheapproachisdesignedtoidentify.SeveralsaidtheyfeltconfidenttheycouldidentifypatientswhohadmoreseriousMHandSUissuesandSBIRhelpedthemidentifythoseonthemiddletolowerendofthescale.One

physiciansaidthatsometimesSBIRscreenedinmildmentalhealthissuesrelatedtonormalnervousnessinpregnancy.Shequestionedwhethertheensuingconversationswereagooduseofhertimeandsuggestedreviewingthequestionstoensuretheylinkedmentalhealthwithproblemsinday-to-dayfunctioning.

ManyofthephysicianssaidthattheyfelttheywerealreadyusingmanyoftheSBIRtechniquesbutSBIRprovidedaddedvalue.SBIRremindedthemtoaskmoreoftenandforsome,earlieroninthepregnancy.Onephysicianprovidedanexampleofapatientwithwhomshehadapositivelong-termrelationshipandSBIRhelpedher

identifyamentalhealthissuethatwasimpactingherpatient’sfunctioning.Shefeltthatshewouldhaveidentifiedtheissueeventually,butSBIRdiditearlierinthepregnancyandshewasabletotalktoherpatientaboutitandreferhertootherresources.

SeveralofthePHCPssaidSBIRprovidesagoodframeworktoaskquestionsaboutsensitivetopicsandopenuptheconversation.Eventhosewhodidnotuseitsaidtheysupportedtheapproach

Itwasverymuchhitandmissbeforehand.

Iknowtherearemanyphysicians,especiallyiftheydon’tseeinfrontofthemaddictionormentalhealthissuesfrequently–thosecanbetoughthingstotalkabout.

Ifitwassomeonewillingtodiscloseormakechanges,we’dleavealittlesheetoutsidetheir(physician’s)doorthathasthepatient’sbloodpressureandweightandurinedip.Iwouldsay:‘Pleaseseemebeforepatient.’


becauseSUandMHissuesareimportanttoscreenforandthetoolwillbeusefultophysicianswhoaren’taccustomedtoorcomfortablewithtalkingaboutthemwithpregnantpatients.

“Itgivesthemaveryniceclearprocessof‘WhatcanIsay?’‘HowcanIsaythat?’‘I’veneverhadtoaskawomanaboutmentalhealthbefore...’or,‘Idon’thavealotofexperiencingdoingthatandhowcanIdoittohaveitworkforbothofus?’Ifindthetoolveryusefulinthatway.”

ManyofthePHCPssaidtheylikedSBIRbecauseitraisedawarenessofMHandSU,conveyedtopatientsthattheseissuesareimportant,andcommunicatedthattheircareproviderscared.Evenifthepatientdidn’tdisclose,therewasasensethattheprocessofaskinghelpedpatientsfeelmorecomfortabledoingsodowntheroad.

“It’splantingaseedthatthisissomethingthatwefeelisimportantandwe’rereadytosupportthemwheneverthey’rereadytomoveforwardinthat.”

Withrespecttothealgorithms,almostallofthePHCPsinterviewedsaidthattheyfoundtheSBIRprocess–introducingitasquestionstheyaskalloftheirpatients–servedtonormalizescreeningandtalkingaboutpotentialproblems.

“Whenwenormalizesomeofthesemoresensitivequestionsthatgivesgreaterpermissionforthepatientstodisclosethingsthattheymightnotnecessarilyfeelcomfortabletalkingabout.”

“Theyknewthattheycouldtalkaboutit,thatitwassomethingthatwewoulddiscusstoday.”

“…[F]ortheprenatalpatient,there’ssomuchnervousnessaboutbringingitupordiscussingit[MHand/orSUissues]thatthisjustkindofmakesitanormalconversationtobehad.”

“We’reasking[so]there’sanawarenessfromthepatientthenthat,maybebeforetheydidn’tthinkthathavingafewjointswasharmfultotheirbaby,andnowthey’rehearing,‘Hey,theykeepaskingmethat,somaybeIshouldtellthemaboutit.”

SeveralPHCPssaidtheylikedhowthetoolguidedthemtoaskpermissionfirst,whichconveyedthatthiswasa“safeplace”totalk.

“Ireally,honestlydon’tthinktheyfeeljudged.Theyfeelsupported.”

ManyPHCPsfoundthattheMItechniquesandskillsusedinSBIRareverytransferabletoworkingwithotherpatientstosupportbehaviourchange.Severalsaidthattheyuseditwithotherpatientsandtheywillcontinuetoincorporateitintotheirpracticeaftertheprojectisover.

“IthinktheskillsareonesthatcanbetranslatedtootherclinicalscenariosandsoIthinkthatthere’ssomevaluethere…usingtheprenatalvisitasanentrypointforthatisveryvaluable.”

“It’sjustmadememoresensitivetousingthemotivationalinterviewingtechniqueswiththispopulationbecausewetendtofeelreallyrushed,andwetendtoreallyhavethephysicalhealthasaprioritybecausethat’skeyinthepregnancy.Ithinkwhatthishasdoneiskindofmademesitbackandremember,okay,thisisreallyimportantandit’simportantthatwestillapproachthis…inapatient-centredfashion.”

“Ithasbuiltanawarenessinme–it’sjustpartofmycarenowforpatients.”

Justhavingthatinitialconversationmadethemcomfortable,that‘okay,ifIdohavesomedaysthatI’mdownandI’mconcernedaboutit,thenIfeelcomfortabletalkingtothemaboutitbecausethey’vetoldmeto’.


SeveralPHCPssaidSBIRallowedthemtohavebetterconversationswiththeirpatientsandonephysiciansaidtheconversationsgaveherabetterappreciationofthebehaviourchangeprocess.

“Ithinkforthemostpartweweregettingtheinformationanyway,butIthinkthatI’mgettingafullerunderstandingofit,andamoreopenconversationaboutitinsteadofjustlikesortofpeoplegivingmetheanswersthatIwanttohear.IthinkitreallyletsmeknowandhelppeopletomaybemakeachangebetterthanIcouldbefore.”...[I]tdoesn’ttakemuchlongertoaskitdifferentlybutIthinkitisaslightlydifferentshiftandIthinkitdoesmakeadifference…[T]here’sstillroomtodoitbetterandtodoitdifferently.”

OnephysiciansaidthatherinitialresponsetoSBIRwasthatsheandhercolleagueswerealreadyusingaveryrelationalapproachwiththeirpatientsandshewasambivalentaboutitsoverallvalue.Midwaythroughtheproject’simplementationperiodshegaveapresentationaboutSBIRtoPHCPsinCapeBretonandshesawaclearerneedfortheapproach.

“Weweren’tevenfinishedandpeoplewerelike,‘Okay,youknow,we’resold.Likehowdoyougetsomeoneupheretoteachushowtodothis?’Therearealotofpeopleouttherethatarenotreallygoodataskingthisandreallywantabettertool.”

SeveralPHCPssaidthatthereisconsiderablevalueinpromotingSBIRmorebroadlybecauseitsupportsthelonger-termhealthofmothersandbabiesandthiskindofearlyinterventionforpreventingmentalhealthandsubstanceusewillreducehealthcarecostsdowntheroad.

Question3:Whataresomecriticalissuesthatemergedfromtheprojectthatneedtobeconsideredmovingforward?

ThekeyinformantsidentifiedimportantissuesthatwillshapetheSBIRapproachmovingforward.

ThelackoftimewithinprenatalvisitsandcompetingpregnancyprioritiesisasignificantbarriertousingSBIR.PHCPswhoparticipatedintheinterviewswereaskedtoidentifychallengesorbarrierstheyencounteredwhenusingSBIR,orwhatpreventedthemfromusingSBIR.ThenumberonebarriercitedbyallrespondentswascompetingprioritiesintheprenatalvisitandthelackoftimetoconductSBIRwhenfacedwithmoreimmediatemedicalissues.

Respondentssaidthatprenatalclinicsareverybusyandoftenrushedtobeginwith;pregnancy-relatedmedicalcomplicationsarecommon,evenifrelativelyminorinacuity,andoncetheyareidentifiedtheytakeimmediatepriority.EventhoughallrespondentssawvalueinhavinganSBIRconversation,theabilitytodoSBIRfrequentlygot“bumped”.

“[Y]outhinkabout,youknow,measuringthewoman’sbloodpressure,whichtakesaminute,let’ssay,andtakinghertothewashroom,lettingherpee,dippingtheurinewhichisanother,threeminutes,let’ssay,altogether,andthenyougetheruponthetableandyou’remeasuringherbellyandyou’relisteningtothefetalheartrate,you’refeelingthe…that’sanotherprobablythreetofourminutes.Andthenyou’vegotalltheotherthingsthatneedtobetalkedabout,you

[W]ejustneedonesmallcomplicationofpregnancytocomeupinthat15minutesandthenthat’sit,that’sourtime…Wenowneedtoaddressthismoreacuteissuethat’sgoingoninthepregnancy….

Forthenormalpregnancy,thatmightbefineandwemightbeabletogettoaskingthosequestionsateveryvisit,butI’dhavetosaythatthatwouldbeunusual.


know,whatevermightbeonthelistforthatdayasfarasthestageofpregnancydo...Womenhavetonsofquestionsthatneedtobeanswered.Youknow,ifthere’sanissueatallwiththepregnancy,thenthathastobesortedout,plusallthepaperworkthatmayneedto…likearequisitionandall,youknow,soit’saprettytightperiodoftimeforthat15minutes.”

“Icanrememberoneday,youknow,wehad18patients,probablytenofthemhadacomplicationthatwaseitherrelatedtobloodpressureorapossiblepulmonaryembolismor,youknow,abdominalpainthatwecouldn’tfigureout,or…andso,youknow,youjustneedoneotherthingandthatjustcompletelyconsumesthevisit.”

“We’reseeingapregnantpatienttoweighher,dipherpee,doherbloodpressure,checkherfundalheight,listentothebaby,askherifshe’sbleeding,askherifanythingiswrongwiththepregnancy,organizingalltheinvestigationsthathavetobedone,andthentryingtofitthisin?”

ThisbarriermaybemagnifiedtosomedegreebecauseitwasresidentswhowereprimarilyusingSBIR.Severalphysiciansnotedthatresidents,particularlyfirst-yearresidents,areoftenoverwhelmedbyeverythingtheyhavetolearnmedicallyaboutcaringforapregnantwomanandhavingtoincorporateanSBIRapproachwasperhapstoomuch.Evenso,itwasclearthatallPHCPsfelttimewasamajorbarriertoSBIRuse,regardlessofone’slevelofexperience.

“[E]venforme,I’manexperiencedphysician,thosefirstprenatalvisitstakealongtime,particularlysincethefirstpregnancytherearesomanyissuesthatneedtobediscussedindetail.”

Onenursesaidthatsometimestheyonlyhaveaboutfourminuteswitheachpatientandthatmakesitverydifficulttohavemorein-depthdiscussionsaboutSUorMH.Sometimeslanguageinterpretersarerequired,whichlimitstimeevenmore.

Partofthetimepressurerelatestothenatureofaddressingmentalhealthandsubstanceuseissues;thesetaketimeandbecausethesystempermitssolittletimeandmedicalissuestakepriority,PHCPsfeeltheycan’triskopeninguptheconversation.

“Idofindthatwhenaskinganextralittlequestion,eventhoughit’ssupposedtobereallyquick,youknow,peopledon’tjustanswer‘yes’or‘no’.Theysay,‘Well,youknow…’andthenyougetabiglong,five-minutedealaboutit.Soitdoesn’talwaysendupbeingquickandit’ssomethingthatIcan’talwaysriskopening…maybesortofaten-minutecanofworms.”

“Sothe15-minuteappointment,acomplicationofpregnancycomesup,it’snowexplodedtohalfanhour,anhour.It’sveryeasytoavoidaskingthequestionsbecausewedon’twanttoopenthatcanofwormsbecausewehavesixotherpeoplewaitinginourwaitingroomforusalready.”

OnePHCPfeltthatasthepregnancyprogresses,theremaybemoretimetoaddresssubstanceuseandmentalhealthissuesbutdelayingthisdefeatsoneoftheobjectivesofSBIR:screeningearlyinthepregnancy.

Otherbarriers.Whiletimeandcompetingprioritieswerethetopissuescitedbyallofthekeyinformants,severalotherswerealsoraised.

I’msupposedtosee18patients,sooverathree-hourperiod,it’slikeanassemblyline…soifsomebodystartstotellyouaboutaproblemorconcernthattheyhave,itreallystallsyouandifIgetstalledthenIholdeverybodyup.


Thefirstwasregardingthecurrentprenatalrecord(PNR)thatonlypromptsaphysiciantoaskaboutsubstanceuseatthefirstpre-natalappointment(andnotatallaboutmentalhealth).SeveralPHCPssaidthePNRshouldberevisedtosupporttheSBIRapproach.

SeveralPHCPsspeculatedonsomeofthebarrierstoanSBIRapproachinfee-for-servicesettings.LackoftimewouldbeespeciallychallengingbecausethesystemencouragesPHCPsto“movequickly”throughpatients.Manyfee-for-serviceclinicsalsodonothaveaccesstonursingresourcesandthiswouldincreasethenumberofactivitiesthatsomephysicianswouldhavetocompletein15-minuteappointments.Similarly,fee-for-servicesettingsprobablydon’thaveaccesstoon-siteaddictionsandmentalhealthservicesandphysiciansmaynotbeawareofwheretoreferpatientsforadditionalsupport.ThismaydiscouragethemfromthereferralaspectofSBIR.

Finally,severalphysicianssaidthereshouldbeabillingcodeforSBIRandthiswouldalleviatesomeofthetimepressures.

“Icanreallyseeinacommunityfamilypracticewheretheyarepaidfee-for-service,youknow,unlessitbecomespartoftheprenatalrecord,it’sgoingtobeverydifficultforphysicianstojustifyutilizingit.Evenifitwasactuallyintegratedintotheprenatalrecord,there’dstillbethetimeconstraint…unless,Ithink,youknow,[thereis]apossiblewaytolookatsubmittinganewfeecodefortheprenatalvisittoextenditbyafewminutesandmakeitworthalittlebitmore.Butthere’sstillalwaysthechallengeofthosecomplicationsofpregnancythatwillovertakethevisit,andIdon’tseeanywayofgettingaroundthatbecausethat’sjustwhathappens.”

UsingSBIRateverypatient’sprenatalvisitmaybeunwarrantedand/or“toomuch”.TheissueofhowoftentousetheSBIRapproachwillneedtobefurtherexplored.Ontheonehand,participantsinthefocusgroupconductedatthebeginningoftheprojectsaidtheywantedtobeaskedaboutMHandSUmorethanonce.Thisissupportedbytheliterature.Ontheotherhand,manykeyinformantssaidthattheytendto“know”ifoneoftheirpatientshasSUorMHissuesandaskingmultipletimesisn’twarranted.

“I’venoproblemwithaskingmorethanonce,especiallywhenit’sareferralpatienttousthatwedon’tknowverywell.But…Imean,I’vebeenworkingatthisjobnowforXyears.SomeofthepeopleIknowreally,reallywell.Soagain,Idon’tthinkit’sabadideatocheckinwhenthey’repregnantonceortwicetomakesurethateverything’sgoingwell.AndIdon’treallymindwithaskingmultipletimesabouttheirmentalhealth,butwhenyou’vegotthatpatientthat,you’veknownforsevenyearsitjustfeelssillytokeepgoing,likeareyousmokingyet?”

OtherPHCPsfoundthataskingeverytimecoulddisruptthebuildingofrapportwhenthepatienthadalreadyindicatedthattheydidn’thaveanyissues.

“Therewasasetofpatientsthatitdefinitelysortofbroketherapportalittlebitbecauseitwassuchastandardizedapproach.Soforsomewomenwho,ifyouhavetogoover,youknow,likethisisyourultrasound,explainingtheMSTandthingslikethat,forthewomenwhoreallyweren’tcomplainingofthese(substanceuseandmentalhealth)issues,it’salllikeanadditionalobstacleandanadditionaltasktoputonthevisitwhichwaskindofdisruptive.”

AsevidencedearlierbythePHCPwhosaidSBIRhelpedheridentifyamentalhealthissueearlierthanshethoughtshewouldhave,PHCPsmaynotalwaysbeabletocountontheirsenseof“knowing”whoisatriskandwhoisn’t.Thepurposeofasking,andaskingrepeatedly,isbasedonresearchthatmanywomenwillnotdisclosebecauseofstigmaassociatedwiththeseissues,evenif


theyhavealongstandingpatient/physicianrelationship.IfPHCPsmakeassumptionsaboutwhethertheirpatienthasissues,thismaystemfromharmfulstereotypes.

Inpart,thisissuecouldbeaddressedinfutureSBIRtrainingthatplacesmoreemphasisondevelopingatrusting,non-judgmentalrelationshipwitheachpatient.AllPHCPsinterviewedcommunicatedthathavingapositiverelationshipwithpatientsisimportantforsupportinghealthypregnancyoutcomes.SBIRwasdesignedtobuildandenhancethatrelationship,butperhapstrust-buildingcouldbebetterintegratedintodefiningtheapproach.OnePHCPwithextensiveclinicalpracticeexperiencesaidbuildingtrustprecedesscreening.

“Peoplecanaskthosequestionsandstillnotdowellwiththis.Youknow,ifyouhaveachecklistandyoujustkindofaskthequestions,thenyou’renotgoingtobeanyfurtherahead.Orifyou’reinahurryandyouseemlike,‘Oh,c’mon,we’vegottogetthroughthis’,obviouslyyouknowpeoplehaveradarforthat.Andthat’snotanatmospherethatengenderstrustandopenness.”

NotallPHCPsusedthetool,orwilllikelyusethetool,inthesameway.TheinterviewsfoundthatuseofSBIRwilldependonclinicalpracticeexperience,thequalityofthepre-existingrelationshipwiththepatient,knowledgeofandexperienceusingMI,andindividualPHCPpersonality.

PHCPswhowereeithernewtoclinicalpracticeand/ornewtoworkingwithpatientsaroundSUandMHissuesmayhaveusedtheSBIRtoolandaccompanyingscriptbecauseitservedasausefulguideforaskingquestionsandhavingconversationsthatperhapstheyweren’tusedto,orcomfortablehaving,yet.NewerresidentsmayalsohaveusedtheSBIRtoolandscriptcloselybecausetheyfeltthiswastheexpectationintheproject.

“Itwasgoodtohavethatpracticebecauseifthequestionsaren’tcomingnaturallyintheprenatalvisit,havingthissortofinyourbackpocket,tosay,‘Idothisforallpatients.”’

Ontheotherhand,asupervisingphysiciansaidthatshewasimpressedwithhowsomeresidentswerealreadysoskilledathavingSBIRconversationswiththeirpatients.Residents(inboththepre-trainingquestionnaireandthosewhowereinterviewed)saidthattheywerefamiliarwithMIandhadreceivedsometraininginitwhentheywereinmedicalschool.

PHCPswhoalreadyhaveapositive,longstandingrelationshipwiththeirpatientsmaynotneedtousetheSBIRapproachinthesamewaytheywouldforanewpatient.

“Whenyou’reanewgradoramorerecentgradyou’restill,youknow,developingyourkindofstyleandapproach.Formanyofmypatients,Iknowthreegenerationsintheirfamilies,soIknowalotaboutthesefamilies,andwhat’sgoingon,whatsocialstructuresthereare.That’sahugelegup(fromsomeonewho)ispregnantandyou’venevermetthembefore,youhavenoideawhattheirsocialcontextis.”

IndividualPHCPpersonalitywilllikelyinfluencehowSBIRisused.SomePHCPshaveapersonalityconducivetorelationshipandtrustbuildingandthiswillmakeintegrationoftheSBIRapproachintotheirpracticeeasier.

“[S]omepeoplehavedevelopedaverynatural,non-invasive,kindandgentle…non-judgmentalwayofaskingaboutthoseparticularissues.Otherphysiciansdon’thavethat.Socertainlyfrom

Somepeoplearegoingtobebetteratthisthanothers,butthebottomlineis,it’sstillgoodtoaskthequestionevenifyou’reaskingitinakindofawkward,roboticway.


apointofviewofgivingpeopleatemplateastohowtheymightaskthosequestionsinanon-judgmental,non-abrupt,non-forcefulkindofway,Ithinkitisveryuseful.”

Question4:Basedonthisproject,whatshouldSBIRtraininglooklikemovingforward?WhatkeyresourcesareneededtosupporttrainingandSBIRuse?

ThemainresourcesdevelopedintheSBIRprojectwere(a)training,(b)algorithms(expandedandbookmarkversions),(c)apatient’sbrochure,(d)videos,and(e)SBIRreminderemails.Basedonthetrainingevaluationsandkeyinformantinterviews,alloftheseresourcesshouldcontinuetobeusedtosupportfutureSBIRtraininganduse.

Training

Thetwo-hourtrainingwaspositivelyviewedbyallPHCPsinterviewed(andinthetrainingevaluations).MostparticipantswerealreadyfamiliarwithMIandthetraininghelpedreinforcesomebasicconceptsandskills.Althoughthetrainingevaluationsfoundthatmanyparticipantswantedmoreopportunitiesinthetrainingtopractice,theinterviewsfoundthatmanyPHCPsfeltthatpracticeneedstohappenintheclinicalsetting.OnePHCPsuggestedmandatoryfollow-uptrainingoncetheyhadaperiodoftimetotestitout.GiventhatsomePHCPsfoundtheBriefInterventionaspectchallenging,thesecondtrainingcould,forexample,focusonit.Therewasanoptionalfollow-uptrainingsession,butmostparticipantsdidnotattend.

MostPHCPsrecognizedtheimportanceofbuildingapositiverelationshipwiththeirpatientsasawaytofacilitatebettercare.Asnotedearlier,buildingtrustiscriticaltopatientsfeelingsafeandcomfortabledisclosinghighlystigmatizedsubstanceuseinpregnancy.OnePHCPsaidshewishedthetraininghademphasizedtheimportanceofbuildingtrust.

What’sbuiltintotrustisnotjudgingpeople.Itseemedtomelikeinthetrainingitwasmorefocusedonyou’vegottoaskthesequestionsratherthantheunderlyingpieceof,‘Youneedtobeopentohearingwherepeopleareatintheirlife,notjudgethem-acceptthemforwheretheyareandbeasupport.’Andthat’sthebestwaytohaveatrustingrelationship.Imean,there’slotsofphysicianswhowillneverhearthattheirpatientsareaddictedbecausethey’renotopentohearingit,andit’sactivelyconcealed.Well,peopledothatforareason…notfornoreason.SoIthinkthatkindofprincipleiswhatIwouldliketoseesortofmoreastheunderlyingpremise,andthentheactualquestionsyouaskarekindofdevicestogetyouthere.

OnePHCPsuggestedthatiftheprojectexpandedbeyondHalifaxRegionalMunicipality,othertrainingmethodscouldbeusedsuchasonlinemodules,ContinuingMedicalEducationsessions,andwebinars.

Algorithms(AppendicesAandB)

MostofthePHCPswhoreportedusingSBIRsaidthattheyusedthealgorithms(eitherfullorbookmarksize)atleastonce.Severalexperiencedphysicianscommentedthattheyfoundthealgorithmscript“artificial”buttheysawthevalueinhavingtheresourcesforPHCPswhoarenewtoSBIR,addressingmentalhealthand/oraddictionsissues,and/orMI.

Whenitcomestodiscussingthereadinesstochange,Ididn’thaveasmuchexperiencewiththatusingthistool.

Ilovedthetool.

Greatprompt/reminder.


“Idon’tgothrougheachsection.Thatfeelsveryartificialtome.SoIaskpermission,thenasksomequestions,andthenaskbasically,wherewouldyouliketogowiththisnow,soundslikeyouhavesomeconcernsaroundfeelingdistressed,whathasworkedwellinpastforyou,wherewouldyouliketogonext?”

Onephysicianalsosaidthatwhenshesawherresidentsstrugglingwiththequestions,thepatientsdidn’tseemtomind.

“[I]t’sstillgoodtoaskthequestions,evenifyou’rejustaskingitinanawkward,roboticway.Thepeoplestillrespondedfinetoitthough.Alotofpatientsdon’tmindiftheirdoctorsarelikethatandthey’reokaywithjustbeingasked.”

OnePHCPwasverysupportiveofhavingthealgorithm,“loved”thequestions–particularlytheaskingpermissionpiece–andattachedthealgorithmtothewallforeasyreference.

Patientbrochure(AppendixC)

PHCPsindicatedinthetrainingandtrainingevaluationsthattheywantedabrochureorresourcetogivetopatientstoinformthemoftheproject.ThefinalbrochureusedimagesofwomenthatreflectedthediversityofNovaScotia’spopulationandwhatonepersonreferredtoas“realpeople.”Nurseswereprobablytheprimaryusersofthebrochure,sincetheyhadfirstcontactwiththepatientsduringprenatalappointments.

“Ifoundthebrochurequitehelpfulasawaytoletwomenknowthatwewereopentotalkingaboutthosethingsandthatpotentiallywouldbepartofthevisit,because…Idon’tknowthatalotofpeoplenecessarilyanticipatementalhealthassomethingthatthey’regoingtobeaskedaboutinpregnancy.”

Motivationalinterviewingvideos(www.behaviourchangeinstitute.ca)

ExamplesofhowanSBIRapproachcanbeusedinaprimarycareclinicalsettingweredevelopedandusedinthetrainingsessions.Lateronintheproject,thesewerepostedtoDr.MichaelVallis’sBehaviourChangeInstitutewebsiteandthePHCPsweregivenaccesstothem.AlthoughitisnotcleariftheMIvideoswereusedbeyondthetrainingsession,severalrespondentssaidtheydidnotfindthemrealistic.Inparticular,theysaidthevideosshowSBIRencountersthattakefivetosevenminutes,whenPHCPsonlyhaveafewminutestointegrateSBIRintotheir15-minuteprenatalvisits.

SBIRreminderemails

OnceSBIRwasformallylaunchedatthetwoclinics,weeklyreminderemailsweresentfromoneoftheprojectco-leads.Theemailscontainedbrieffactsaboutwomen,pregnancy,andSUand/orMH.PHCPswereencouragedtoemailwithanyquestions.

Inthekeyinformantinterviews,severalPHCPsmadeapointofsayingtheyfoundtheseweeklyemailstobeusefulremindersforthemtousetheSBIRapproach,whichtheymightotherwisehaveforgotten.WithoutaPNRtoremindPHCPstouseSBIR,emailremindersmayserveapurposemovingforward.


6. MOVINGFORWARD

Ultimately,thekeyquestiongoingforwardis:WhatisanSBIRapproachthatcanbeadvancedforfurtheruseinNovaScotia?ThissectiondiscussessomekeylearningsandimportantprinciplesforplanningandimplementingtheSBIRapproachinthefuture.

6.1 Keylearnings

ThisprojectprovidedvaluableinformationaboutwhatisgoingtoberequiredinorderforPHCPstouseSBIRinclinicalpracticewithpregnantpatientsandnewmothers.Somekeylearningsinclude:

1. Thelackoftimeandcompetingprioritieswereseenassignificantbarriersforprimaryhealthcareprovidersto“doingSBIR”.WhenpresentedtotheSteeringCommitteeandthetrainer,theresponsetothisfeedbackwasthatitisunfortunatePHCPsseeSBIRasan“add-on”,notasanapproachtheycanintegrateintotheirgeneralpractice.ThispointstoapossibledisconnectbetweenwhattheSteeringCommitteeandtrainerseeastheessenceofSBIR(an“approach”)andwhatisunderstoodbyPHCPsandpossiblyemphasizedinthetraining(a“tool”).Thetrainingmayneedtoberevisedtoplacegreateremphasison“theapproach.”FocusonthealgorithmimpliesthataskingtheS-BI-RquestionsisthemostimportantpartofSBIR.Focusontheapproachemphasizesusingtheprinciplesofrelationalcareandbeingnon-judgmental.Evenwithafocusontheapproach,itisstilllikelythattimewillbeanongoingissue.

2. Mandatoryfollow-uptrainingisworthtrying.ThesecondtrainingsessioncouldemphasizedoingBriefInterventionandsupportingPHCPstolearnhowtoeffectivelyworkwithambivalence.Thiswouldbeanotheropportunitytoemphasizetheimportanceofbuildingtrustandrelationships.

3. SBIRmaynotneedtobeusedateveryprenatalvisitwitheverypatient.OneofthekeyprinciplesofSBIRisthatitshouldbeusedwithallpatients,notjustthosewhoappeartobe“atrisk”.Allpregnantpatientsshouldbeaskedinanon-judgmentalwayabouttheiralcohol,tobacco,andotherdruguseandtheirmentalhealth.However,careproviderscanexercisegoodjudgmentaboutthefrequencyofusingSBIR,dependingontheirrelationshipwiththepatient.Continuingtoaskpregnantpatientsatregularintervalsisimportant,nomatterwhat.People’slivesandhabitschange,andpatientsmaybemorelikelytospeakopenlyaboutsubstanceuseormentalhealthwhentheyhavevisitedthecareproviderrepeatedly.

4. SupportingSBIRresources,suchasthealgorithms,brochure,videos,andemailreminders,werepositivelyreceivedbyPHCPs.Theseresourcescanbemodifiedtoreflectthefindingsfromthekeyinformantinterviews.

5. PHCPsarebeingaskedtochangethewaytheypracticeandinteractwiththeirpatients;developingcomfortandconfidenceusingSBIRtakestime.PHCPshaverichpracticeandformaleducation-basedknowledgeandskillstheycandrawuponwhenusinganSBIRapproach.Lengthofclinicalpracticeexperience,comfortaddressingSUandMHissues,naturalabilitytodevelopandsustaintrustingpatient-physicianrelationships,andindividualPHCPpersonality,willallimpactaPHCP’seffectiveuseofSBIR.TraininginandpromotionofSBIRcanacknowledgethisupfronttoallowPHCPstofeelcomfortableadaptingtheapproachtofittheiruniquepracticestylesandvaryinglevelsofknowledgeandexperience.


6. HowSBIRwasusedinoneclinic–nursesusingSBIRandthennotifyingphysiciansiftheyscreenedforanissue–isworthexploringfurther.ArecentAmericanstudyfoundthatuseofSBIRbymedicalassistants,withreferralbyphysiciansasneeded,wasafeasiblemodel(Mertens,etal.,2015).

7. Addressingsystem-levelissuessuchasrevisionstotheprenatalrecord(PNR)couldinfluencetheuptakeofSBIR.

6.2 PrinciplesofplanningandimplementingtheSBIRapproach

Inthisproject,anumberofprinciplesemergedforplanningandimplementingtheSBIRapproachindifferentkindsofprimarycaresettings.

1. Listento,engagewith,andassesstheneedsofprimaryhealthcareprovidersintheirspecificsettings.Thisprojecttookplaceinacollaborativecareteachingclinicwithmanyco-locatedservices,includingaddictionsandmentalhealth.Leadinguptothelaunch,aseriesofmeetingsanddiscussionshelpedusunderstandwhattheseHCPsneededandwhatkindsoftrainingandimplementationwerelikely–ornotlikely–towork.Thiscrucialfirststepsetthestageforcreatingtraining,tools,andsupportsthatwereresponsivetofeedbackfromusersandtheSteeringCommittee.LiketheSBIRapproachitself,buildingafoundationoftrustandcommunicationwasveryimportant.

2. Engagewithpartnersandthecommunityasacriticalfirststep.Wespentseveralweekscallingandvisitingwithprofessionalsandcommunitygroupstoinformthemabouttheprojectandanswerquestions.Insomecases,thisengagementresultedinactiveparticipationintheproject.Inothers,wegainedknowledgeandinformationaboutavailableresourcesandbuiltrelationshipsthatenhancedourwork.Wefoundthatitwasimportanttoallayconcerns,particularlyamongaddictionandmentalhealthprofessionals,thattheprojectwouldincreasetheirworkloadorputunreasonabledemandsonservices.

3. Mapcommunityassetsandservicestounderstandthecontextpatientsandfamiliesarelivinginandwhatservicestheyhaveaccessto.Reducingharmmeansrecognizingthatpatientsneednotonlynon-judgmentalsupportandadvicefromHCPs.Theyneedacomprehensiveapproachtotheirphysical,psychological,andsocialhealththattakesintoaccountthemanyfactorsthatcontributetosubstanceuseandmentalhealthissues.Thesefactorsincludepoverty,foodinsecurity,domesticviolence,lackoftransportation,inadequatehousing,andotherchallenges.Ourassetmappingrevealedmorethan50communitygroups,charities,churches,governmentagencies,non-profitorganizations,medicalandsocialservicecentres,andpoliceservicesinthecommunitiesservedbythetwoclinics.Inaddition,themappingidentifiedformalpathwaystomentalhealthandaddictionservices,manyofwhichwereco-locatedintheclinics.Whencareprovidershaveconvenientaccesstoinformationforarangeofbothprofessionalreferralsandpatientself-referrals,theyareprobablymorelikelytouseSBIR,becausetheyfeelconfidentthatadequatesupportsexisttosupportpregnantpatientsandnewmotherswhoneedthem.

4. Assembleadiverseadvisorygrouptobringvaluableperspectivesandresourcestotheproject.TheSteeringCommitteemembersarelistedonpagefiveofthisreport,andincludephysicians,anurse,apsychologist,substanceuseandmentalhealthexpertsfromtheprovinceandthefederalgovernment,andacommunitymember/patientrepresentative.Committeemembersdidnotalwaysagreeonhowtheprojectshouldmove


forward,butrichdiscussionscontributedtotrainingandresourcesthatmeettheneedsofdifferentcareproviders.

5. Emphasizetrauma-informedandwomanandfamilycentredcareinmaterialsandtraining.UnderstandingwhySBIRmattersandwhyitworksisfoundationaltousingit,andbuildingmoreemphasisontraumaandlivedexperiencesintothetrainingmayhelpcaregiversintegratetheSBIRapproachmoreseamlesslyintotheirdailypractice.

6.3 Nextsteps

DemonstratingthetransferabilityofSBIRtodifferentprimarycaresituationsandcontextsisthenextstepinpropagatingtheSBIRapproachinNovaScotia.Thereisnoquestionthatsystem-levelissuessuchaslimitedappointmenttimes,thefee-for-servicemodel,andlackofabillingcodeforscreeningmightpresentevengreaterchallengesinmoretypicalprimarycaresettings.MostdoctorsinNovaScotiapracticeontheirown,andmanyhavelimitedsupportstaff.Still,ourprojectfindingspointtopromisingpossibilitiesforintegratingSBIRintodifferentprimarycaresettings.Physicians,nurses,nursepractitioners,andothercareprovidershaveagreatdealofeducation,experience,andskill.Manyarealready“doing”SBIRbybuildingtrustingrelationshipswiththeirpatientsandcreatingspaceforrespectfulandnon-judgmentalconversations.ThisisagreatfoundationonwhichtobuildSBIRskillsandcompetencies.

Theprojectteamcanbuildontherichfindingsfromthisproject,aswellaslearnfromSBIRpilotprojectsinManitobaandtheAustralianmodel,tocontinuetodevelop,“test”,andevaluatetheuseofSBIRindifferentNovaScotiaprimarycaresettings.TheprojectteamisalreadywellawarethatfutureprojectsshouldincludethedevelopmentofculturallysafeSBIRapproachesforusewithpeoplefromdiverseculturalandsocio-economicbackgroundsandhistories.Collectingfeedbackfrompatientsisalsocritical.

MembersoftheSBIRteamhavemetwithprimarycareproviders,mentalhealthandaddictionsstaffandleaders,hospitalandcommunitybasedproviders,andfamilyresourcecentrestaffmembersintwoothersitesinNovaScotiatodiscussthelessonslearnedfromtheSBIRproject.Allthosewhocareforpregnantpatientsandnewmothersagreethatsubstanceuseandmentalhealtharehighpriorityareas,andthereisgreatinterestinbuildingSBIRcompetencyinotherpartsoftheprovince.TherehavealsobeenongoingdiscussionswiththeFirstNationsInuitHealthBranch(FNIHB)AtlanticregionteamforanSBIRprojectinseveralFirstNationscommunitiesinNovaScotia.

Overall,itwasclearthattherewasstrongsupportforongoingdevelopmentofanSBIRapproachtoworkingwithpregnantpatientsandnewmothers.Thetwoteachingandreferralclinicsinvolvedinthisprojectareoftenaskedtobedemonstrationsitesforavarietyofprojects.Thismaybeduetothecollaborativearrangementoftheclinic,theco-locationandaccesstootherservices,orbecausetheyareformalteachingsites.TestingSBIRinotherprimaryhealthcaresettingswillprovideadditionalinsightsintohowSBIRcanbeimplementedsuccessfully.


AppendixA:SBIRAlgorithmsSBIR-Screening,BriefIntervention&Referral

MENTALHEALTHforPregnantPatients&NewMothers:AGuideforCareProviders

SBIRisanapproachtoaskingquestions,notascriptyoumuststickto!AsyoupracticeSBIRwithyour

patients,youwilldevelopyourownstyle.TheimportantthingistofollowthebasicstepsofAsk,Listen,Summarize,Invite.SBIRshouldberepeatedregularlywitheachpatient.

Breaktheice.

“Aspartofyourcare,couldIaskyouacoupleofquestionsaboutyourmentalhealth?Iaskeveryonethesequestions.Theywillhelpmeunderstandyourday-to-daylife,sowecanplanyourcaretogether.”

“Inthepastmonth…Haveyouoftenfelt

distressed?Haveyoufeltdownanddepressed,anxiousandworried,orirritableand

angry?”

“Haveyouhadahardtime

functioninginyourrelationshipsorgetting

thingsdonebecauseyoufeltdistressed?”

“Haveyoulostinterestinoravoidednormalactivities?”

----

Youaregaugingthelevelofdistressandthelevelofinterferenceinthe

patient’sdailylife:Presence,Severity,Impact

LISTEN.

IftheanswerisNO

toallthequestions:

“Thankyoufortalkingwithmeaboutyourmentalhealth.Itsoundslikeyou’redoingwell.Wecantalkaboutthisagaintomakesureyouarestillfeelinggood.Ifyouhavequestionsorconcerns,wecantalkaboutmentalhealthanytime.”

---Youcantalkabouthowahistoryof

mentalhealthchallengesisariskfactorformentalhealthchallengesinpregnancy

orpost-partum.

IftheanswerisYES

toanyofthequestions:

“Thankyouforsharingthiswithme.Sometimesit’sverydifficulttotalkaboutmentalhealth.Nowwecanworktogethertohelpyoufeel

better.”---

Furtherassessmentisrequired.

2.BRIEFINTERVENTION

ShowEMPATHY.

Reflectbackwhatyou’veheardfromyourpatient:

“WhatIhearyousayingisyou(feel/think/areaparticularway)regardingmentalhealth.”Invitetheconversationforchange:

“Canwetalkabout…?”

SUMMARIZE.

1.SCREENING

ASK.

ASKPERMISSIONtodiscussthetopicfurther.

“Wouldyoumindifwetalkedforafewminutesabouthowyou’vebeenfeeling?”

“Canwetalkabouttherisksof…?”

Shownon-judgmentalCURIOSITY.“Canyouhelpmeunderstandwhatyourexperienceislike?”

“Iamreallyinterestedinknowinghowyoufeel.”

TIPSforMotivationalCommunicationMaximizequestions.Minimizestatements.Beginofferingchangesoroptionswith,“Wouldyouconsider…”Conveyafamily/woman-

centeredandrelationalapproach.

Uncoverandsitwithambivalence.Exploretheprosandconsofchange.

Startwithreasonswhythebehaviour

makessenseforthepatient.

Althoughtheneedtostopcertain

behavioursmightseemobvious,

thereisusuallyareasonwhythey

persist.

Avoidargument.Ifthepatientsays,“Yes,but…”,respondbysaying,

“Whatyouaretellingmeisyou’renotreadytomakeachangebecause…”Thisclarifiesthepatient’sintentand

experience.

Rollwithresistance.Thepatientmay

say,“Itriedanditdidn’twork.”Use

thisasanopportunityforlearning.

Say,“Thankyoufortrying–Canwetakealookatwhathappened?”Remindthemthatyouareworking

together.

Supportself-efficacy.Bemindfulof

thepatient’sconfidenceintheir

specificlifecontext.Peoplehave

complexlivesand,sometimes,

traumatichistoriesandexperiences.

Don’tbeafraidtoacknowledgethat

lifecanbedifficult!

NOTmakingachoiceisstillachoice.Yourroleistoidentify,educate,

recommend,andsupport.

Remember:Youdon’thavetobeanexpert!

NOTREADY:Listentothepatient’sstory.Explorepersonaland

meaningfulreasonstochange.Keep

theconversationgoing.Askagain

nexttime.

AMBIVALENT:Listentothepatient’sstory.Explorepersonal

andmeaningfulreasonstochange.

READY:Negotiateaplanforchange.RememberthatharmreductionIS

change.

Ifnecessary,thepatientmaybereferredorencouragedto

self-referto:

• Mentalhealthandaddictionservices,NovaScotia

HealthAuthority

• CommunityHealthTeam

• FamilyResourceCentre

• PublicHealth

• Othersupportsandservicesinthecommunity

AssessREADINESSTOCHANGE:4keyquestions

1. Isthisbehaviouraproblemforyou?2. Areyoudistressedbythisproblem?3. Areyouinterestedinmakingachange?4. Areyoureadytochangenow?ORWhenwould

youliketomakeachange?---

Thiscanbeanopportunitytobookanotherappointment

ortakeafirststepandcheckinatascheduledtime.

3.REFERRAL–Nextsteps

Thisresourceisadaptedfromtheworkof

Dr.MichaelVallisandhiscolleaguesatthe

BehaviourChangeInstitute.Youwillalso

findSBIRtrainingvideoshere:

www.behaviourchangeinstitute.ca

TheSBIRDemonstrationProjectisaninitiativeoftheNovaScotiaDepartmentof

HealthandWellnessandwasmadepossible

byfundingfromtheDrugTreatment

FundingProgramofHealthCanada.

Youarewelcometouseandmodifythistooltofityourhealthcarecontext.Ifyoudo,

pleasenotethatitisadaptedfromtheNovaScotiaSBIRProject.

INVITE.


Step1:“Pleasetellmeaboutyour

alcoholdrinkinghabitsbeforeyoubecamepregnant.”

“Pleasetellmeaboutyouruse

ofothersubstancesbeforeyoubecamepregnant,like

marijuana,cocaine,narcotics,

orprescriptiondrugs.”

“Pleasetellmeaboutsmokingbeforeyoubecamepregnant.”

----

Step2:IFthepatientrespondswitha

patternofuse…

“Thankyouforsharingthis

withme.Itcanbehardtotalk

about

drinking/smoking/drugs.”

“CanIaskifyouare

drinking/smoking/usingdrugs

nowthatyouarepregnant?”

LISTEN.

IFthepatientdoesnotdrinkoralcoholusewaswithintheCanadianlow-riskdrinkingguidelinesbeforepregnancyANDtheydonotsmokeorquitatleast5

yearsagoANDtheyhavenotusedordonotuseany

othersubstances:

“Thankyoufortalkingwithmeaboutthis.

We’lltalkaboutthisagainthroughoutyour

pregnancy.Letmeknowifyouhave

questionsorconcerns.”

---Youcanreinforcehealthymessagesabout

substanceuseduringpregnancy.Saythatresearchhasnotestablishedanysafeamountofalcoholor

drugsduringpregnancy.

IFthepatientdisclosesthattheyusealcohol,smoke,and/oruseother

substances:

“Thankyouforsharingthiswithme.It’svery

difficulttotalkabout

drinking/smoking/usingdrugs.

Pleasetellmemore.”

Furtherassessmentisrequired.

2.BRIEFINTERVENTION

ShowEMPATHY.

Reflectbackwhatyou’veheardfromyourpatient:“WhatIhearyousayingisyou(feel/think/areaparticularway)aboutdrinking/smoking/druguse.”

Invitetheconversationforchange:“Canwetalkabout…?”

SUMMARIZE.

ASK.

SBIR-Screening,BriefIntervention&ReferralSUBSTANCEUSEforPregnantPatients&NewMothers:

AGuideforCareProviders

SBIRisanapproachtoaskingquestions,notascriptyoumuststickto!AsyoupracticeSBIRwithyourpatients,youwilldevelopyourownstyle.TheimportantthingistofollowthebasicstepsofAsk,Listen,

Summarize,Invite.SBIRshouldberepeatedregularlywitheachpatient.

Breaktheice.“Aspartofyourcare,couldIaskyousomequestionsaboutsmoking,drinkinganddrugs?Iaskeveryone

thesequestions.Theyhelpmeunderstandyourday-to-daylife,sowecanplanyourcaretogether.”

Ifnecessary,thepatientmaybereferredorencouragedto

self-referto:

• Mentalhealthandaddictionservices,NovaScotia

HealthAuthority

• CommunityHealthTeam

• FamilyResourceCentre

• PublicHealth

• Othersupportsandservicesinthecommunity

ASKPERMISSIONtodiscussthetopicfurther.

“Wouldyoumindifwetalkedforafewminutesabouthowyou’vebeenfeeling?”

“Canwetalkabouttherisksof…?”

Shownon-judgmentalCURIOSITY.“Canyouhelpmeunderstandwhatyourexperienceislike?”

“Iamreallyinterestedinknowinghowyoufeel.”

TIPSforMotivationalCommunicationMaximizequestions.Minimizestatements.Beginofferingchangesoroptionswith,“Wouldyouconsider…”Conveyafamily/woman-

centeredandrelationalapproach.

Uncoverandsitwithambivalence.Exploretheprosandconsofchange.

Startwithreasonswhythebehaviour

makessenseforthepatient.

Althoughtheneedtostopcertain

behavioursmightseemobvious,

thereisusuallyareasonwhythey

persist.

Avoidargument.Ifthepatientsays,“Yes,but…”,respondbysaying,

“Whatyouaretellingmeisyou’renotreadytomakeachangebecause…”Thisclarifiesthepatient’sintentand

experience.

Rollwithresistance.Thepatientmay

say,“Itriedanditdidn’twork.”Use

thisasanopportunityforlearning.

Say,“Thankyoufortrying–Canwetakealookatwhathappened?”Remindthemthatyouareworking

together.

Supportself-efficacy.Bemindfulof

thepatient’sconfidenceintheir

specificlifecontext.Peoplehave

complexlivesand,sometimes,

traumatichistoriesandexperiences.

Don’tbeafraidtoacknowledgethat

lifecanbedifficult!

NOTmakingachoiceisstillachoice.Yourroleistoidentify,educate,

recommend,andsupport.

Remember:Youdon’thavetobeanexpert!

NOTREADY:Listentothepatient’sstory.Explorepersonaland

meaningfulreasonstochange.Keep

theconversationgoing.Askagain

nexttime.

AMBIVALENT:Listentothepatient’sstory.Explorepersonal

andmeaningfulreasonstochange.

READY:Negotiateaplanforchange.RememberthatharmreductionIS

change.

AssessREADINESSTOCHANGE:4keyquestions

1. Isthisbehaviouraproblemforyou?2. Areyoudistressedbythisproblem?3. Areyouinterestedinmakingachange?4. Areyoureadytochangenow?ORWhenwould

youliketomakeachange?---

Thiscanbeanopportunitytobookanotherappointment

ortakeafirststepandcheckinatascheduledtime.

3.REFERRAL–Nextsteps

INVITE.

Thisresourceisadaptedfromtheworkof

Dr.MichaelVallisandhiscolleaguesatthe

BehaviourChangeInstitute.Youwillalso

findSBIRtrainingvideoshere:


TheSBIRDemonstrationProjectisaninitiativeoftheNovaScotiaDepartmentof

HealthandWellnessandwasmadepossible

byfundingfromtheDrugTreatment

FundingProgramofHealthCanada.

Youarewelcometouseandmodifythistooltofityourhealthcarecontext.Ifyoudo,

pleasenotethatitisadaptedfromtheNovaScotiaSBIRProject.


AppendixB:AlgorithmBookmark

SBIR–MENTALHEALTH

ForPregnantPatients&NewMothers

2.BRIEFINTERVENTIONSummarizewhatyou’veheard.Invite.Askpermissiontotalkmore.Assessreadinessforchange:• “Isthisaproblem?Areyouupsetaboutit?”

• “Areyouinterestedinachange?”• “Areyoureadytochange?”NOTREADY:Listen.Askagainnexttime.AMBIVALENT:Listen.Explorepersonalreasonstochange.READY:Negotiateaplan.

1.SCREENINGAsk.“Haveyoufeltdown,anxious,irritable,orangry?Hasthisaffectedyourdailylife?”Gauge:Presence,Severity,ImpactListen.Thankyourpatient.Say,“It’shardtotalkaboutmentalhealth.”Ifpatientsaysyes,gotothenextstep.

3.REFERRALIftheproblemissevere,refer.

SBIRDemonstrationProject–NSDept.ofHealthandWellness,fundedbyHealthCanada’sDTFP

Pleasefeelfreetouseandmodifythistool,notingthatitisadaptedfromtheNovaScotiaSBIRProject.

SBIR–SUBSTANCEUSEForPregnantPatients&NewMothers

2.BRIEFINTERVENTIONSummarizewhatyou’veheard.Invite.Askpermissiontotalkmore.Assessreadinessforchange:• “Isthisaproblem?Areyouupsetaboutit?”

• “Areyouinterestedinachange?”• “Areyoureadytochange?”NOTREADY:Listen.Askagainnexttime.AMBIVALENT:Listen.Explorepersonalreasonstochange.READY:Negotiateaplan.

1.SCREENINGAskyourpatientaboutdrinking,smokinganddruguse–beforeandafterbecomingpregnant.Gauge:Presence,Severity,ImpactListen.Thankyourpatient.Say,“It’shardtotalkaboutsubstanceuse.”Ifpatientisusingsubstances,gotothenextstep.

3.REFERRALIftheproblemissevere,refer.

Youdon’thavetobeanexpert!AdaptedfromtheworkofDr.MichaelVallis



AppendixC:BrochureforPatients


AppendixD:Datacollectionpointsandpurpose

PhaseI:DevelopmentofSBIRapproachandtraining

Datapoint PurposeLiteraturescan Useevidence-informedapproachforthe

developmentoftheSBIRapproachOngoingplanningmeetingwithSBIRadvisorycommittee

GaininputandfeedbackfromkeystakeholdersonSBIRdevelopments

Focusgroupwithpregnantwomenandnewmothers

Understandpatients’currentexperienceswithinPHCsettingtoinformapproach

Pre-trainingsurveyofPHCPs UnderstandpreviousexperiencewithMotivationalInterviewing(MI)andlearnabouttrainingneeds

Trainingsessionsobservationandevaluationsurveyoftrainees

Learnhowtrainingwasdeliveredandmodifybasedonfeedback

ReviewofSBIRresources(algorithm,bookmark,andpatientbrochure)

EnsureresourceswerehelpfulandeasytousebyPHCPs;ensurebrochure

Interviewwithtrainer Gainhisperceptionsontrainingandrequiredmodifications

FocusgroupwithcoreSBIRteamandtrainer Reflectonlearningstodate;plansecondtrainingsession

PhaseII:UseofSBIRapproach

Datapoint PurposeSecondtrainingsessionobservationandevaluationsurvey

LearnwhetherPHCPshavetriedSBIR;understandinitialexperiences

FirstanalysisofSBIRuptakedata(throughPractimax)

LearnextenttowhichPHCPsareusingSBIR

SecondanalysisofSBIRuptakedata(throughPractimax)

LearnextenttowhichPHCPsareusingSBIR

InterviewswithPHCPs LearnabouttheexperiencesofPHCPsusing(ornotusing)SBIRwithpatients

SharedinterpretationofkeyinformantinterviewdatawithcoreSBIRteamandsteeringcommittee

Communicationoffindingsfromkeyinformantinterviewsandfinalprojectreflectiononlearnings


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