Implementation of the BNI

How to get started

• Buy in- Gaining staff support and buy-in at both an organizational and community level is a key element in any implementation effort. Organizational leaders must provide resources and support for successful implementation. Staff members are more likely to participate in training and adoption of SBIRT if involved in planning from the start. It is crucial to partner with other institutional resources, e.g., social work, health educators and outside resources e.g., specialized alcohol and drug treatment programs and services, to ensure patients have the necessary follow up. This may include reinforcement from primary care providers, brief treatment or specialized treatment for more severe disorders
• Assessment of Clinical Practice Site and Available Providers- Before implementing the BNI in your practice site you should conduct a brief assessment to see how the BNI will be incorporated into your organization. Several factors should be considered such as available staff, workflow, space, time and organizational structure. A planning and development phase will be necessary to elicit and secure support of personnel on all levels. Implementation of the BNI will require planning and flexibility to ensure long term sustainability.
  
• Identify and Partner with Community Services- In some cases, additional treatment options such as brief treatment, intensive substance abuse treatment and/or community groups such as AA or NA may be necessary. It will be essential to develop a range of community referral relationships, to ensure that patients with different types of needs, cultural backgrounds and insurances receive the appropriate level of care after the BNI has been administered.

Training and Curriculum

• Identify Champions-The Champion will be someone who leads the BNI training effort and is knowledgeable about the target population and the site where the BNI is being implemented. Champions need to be identified and recruited in each practice discipline (e.g. nurse, social worker, mid-level, physician)

• Didactic Presentation (1 hour): The didactic presentation orients participants to the fundamentals of MI and the the steps of the BNI using a video and slides.
• Skills based practice (1 hour): Trainees work in role play triads, practice the SBIRT skills, and receive feedback from their peers and the trainer.
• Direct observation and feedback (30 mins): Participants receive further training in screening and other drug (AOD) (10 minutes) and performing intervention and referral (20 mins).

Adoption into the Clinical Area

Screening is the first part of the BNI and can be administered using a brief questionnaire to your patients. As part of the planning process leading up to the implementation of the BNI your institution will benefit from considering patient flow and available resources, when deciding what screening tools should be used and how they should be administered.

Some things to consider:

• Who will perform the screening or be responsible for its completion? (e.g. receptionist, nurse, health educator, physician )
• How will the screening be performed (e.g. self-administered, paper, ipad etc. or by staff)
• Where will the screening be performed? (e.g. waiting room, triage area, patient room)
• What screening tools will you use? (e.g. NIAAA single questions screen or AUDIT etc)

To provide an effective BNI the practitioner will need to know the results of the initial screen. It is possible that the practitioner may need to ask a few more questions regarding screening and assessment to proceed with the BNI, depending on the initial type of screen. This information is necessary to perform the BNI, motivating the patient to change their alcohol and drug use patterns. Most likely all members of the treatment team should be trained in principles of MI and the BNI to ensure each patient with a positive screen has the opportunity to receive an intervention.

• Who will conduct the BNI?
• When will the BNI be delivered?
• What immediate resources are available on site for urgent/severe problems that are identified? (e.g. social work, health educators)
• What community specialty services are available for referral?

Quality Assurance Measures

Implementation of the BNI should fit into Continuous Quality Improvement (CQI) initiatives similar to all other health practices. This would include monitoring number of patients screened, BNIs performed after positive screens, number and types of referrals. Quality Assurance is maintained during training of the BNI using the BNI Adherence and and Critical Actions Checklist. All practitioners should receive immediate feedback from this exercise and those with significant skill deficit can be retested after remediation. Skill decay can be addressed by periodic booster sessions and monitoring performance using the checklist.

Example of Implementation:

Yale SBIRT Residency Training Program using the BNI

• Buy-In- Buy in was garnered from the Council of Residency Directors at the Outset of the program. Faculty team leaders have been drawn directly from leaders of specific specialty programs who are passionate about creating and disseminating scholarship on screening and intervention. The SBIRT project team and faculty leaders have significant history with alcohol and substance research and treatment. Their knowledge has provided a foundation for buy-in within departments and across program area. In addition, team leaders are involved in evaluating, tailoring and teaching the curriculum to accommodate unique departmental training requirements.
  • Community Partners- The Yale SBIRT Program partners with Project ASSERT, which provides health promotion advocates who are peer educators/interventionists to help patients access primary care and drug and alcohol treatment services. Project ASSERT utilizes its network of community partnerships and linkages to provide referrals
    
• Faculty Champions- The Yale University Medical Residency Training Program utilizes a physician implementation model. Each residency site must designate at least one faculty champion to train residents and facilitate the integration of SBIRT into clinical practice. A percentage of the faculty champions salaries are funded by the grant.

Training and Curriculum

The medical residency training program defines a training event as at minimum a 3 hour training session. Each residency program uses the core curriculum, materials and training exercise concepts as a foundation and then adapts the training program to meet its specific scheduling and practice needs

What makes our program work:

• All training is integrated into existing educational programs and procedures are incorporated into practice settings.
• Training sessions are tailored by specialty area using relevant case-specific materials.
• All sessions use multiple educational techniques including didactic presentations, role-play, and use of standardized patients with observation.
• The curriculum is web-based and available to all 24 hours a day.
• BNI adherence checklists are used to ensure quality performance.
• Champions are engaged and trained in each specialty to serve as role models and resources for the staff to ensure sustainability.
• To motivate residents in the millennial generation, training might include an array of strategies that include team/group work, technology and visual learning.