Community Paramedicine

2019 Community Paramedicine Course

FST3043/6043: Community Paramedicine

This course is designed to examine best practices in Community Paramedicine, including Quick Response Teams visiting homes of those saved by Narcan. Fire/EMS agencies are finding unique solutions to combat the issues that our communities face daily, including heroin overdoses and frequent 911 calls.

  • 3-Day Residency: March 18–20, 2019
  • 3 credit course
  • 1-credit option available: $459, for Ohio residents (and IN / KY reciprocity areas)

Speakers

  • Lawrence Bennett, Fire Science Program Chair
  • John Centers, City of Monroe Fire Chief 
  • Paul Miller, Crawfordsville, IN EMS Div. Chief 
  • Neil MacKinnon, UC Pharmacy Dean
  • JD Postage, Violet Township Lieutenant
  • Will Mueller, Colerain Asst. Fire Chief
  • Mike Rosen, Center for Addiction Treatment

March 18, 2019

March 19, 2019

March 20, 2019

Free Seminar 
8:30 am–noon

Lead the change in your community! Join UC Fire Science for a free seminar and panel discussions on community paramedicine, including topics like quick response teams, safe station programs, and local hospital partnerships.

  • Continuing Education certificates of attendance will be issued
  • No charge for attendance
  • No RSVP required

Location:
Center for Addication Treatment
830 Ezzard Charles Drive, Cincinnati, OH 45214

Course Presentations

Angela Clark, PhD, RN- Assistant Professor, Univ of Cincinnati, College of Nursing 

 

Objectives

The purpose of this module is to learn about using Screening, Brief Intervention, and Referral to Treatment (SBIRT) within the Appalachian community. By the end of this module learners should be able to:

  • Identify the risks and prevalence of substance use among the Appalachian population.
  • Understand the components of screening, brief intervention, and referral to treatment (SBIRT).
  • Identify validated screening instruments that can be used to evaluate substance use.
  • Identify barriers and benefits of SBIRT with the Appalachian population
Why Learning About Substance Use Screening in the Appalachian Community?
  • Substance use has increased steadily in rural Appalachia over the past two decades (Centers for Disease Control and Prevention [CDC], 2011; Havens, Walker, & Leukefeld, 2007).
  • People living in coal mining regions, specifically those with mountaintop coal removal, are at increased risk of developing substance use disorders (Steele, 2015, Zhang et al., 2008).
  • The Affordable Care Act requires that insurance companies (Goodman, 2013):
    • Reimburse providers for providing alcohol and drug screening
    • Provide coverage for SUD treatment.

 

Drug Overdose Death Data
  • Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999.
  • West Virginia had highest overdose-death rate in the country in 2016 (52.0 per 100,000).
  • Ohio ranked 2nd (39.1 per 100,000), Pennsylvania 4th (37.9 per 100,000, and Kentucky 5th (33.5 per 100,000).
What Does SBIRT Stand For?

An intervention based on “motivational interviewing” strategies

  • Screening: Universal screening for quickly assessing use and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse (for pregnant women assess for the presence of any substance use).
  • Brief Intervention: Brief motivational and awareness-raising intervention given to risky or problematic substance users.
  • Referral to Treatment: Referrals to specialty care provided for those identified as needing more extensive treatment information.

Treatment may consist of brief treatment or specialty AOD (alcohol and other drugs) treatment. 

The Moving Parts of SBIRT
  • Pre-screening (universal – all patients receive annually)
  • Full screening (for those with a positive pre-screen)
  • Brief Intervention (for those scoring over the cut off point)
  • Extended Brief Interventions or Brief Treatment (for those who have moderate risk or high risk use of substances and would benefit from ongoing, targeted interventions, and are willing to engage)
  • Traditional Treatment (for those who have a substance use disorder (after further assessment) (and are willing to engage)
Short & Long Term Health Care Costs
  • By intervening early, SBIRT saves lives and money and is consistent with overall support for patient wellness.
  • Late-stage intervention and substance abuse treatment is expensive, and the patient has often developed comorbid health conditions
SBIRT- Screening
  • Screening is the first step of the SBIRT process and determines the severity and risk level of the patient’s substance use.
  • The result of a screen allows the provider to determine if a brief intervention or referral to treatment is a necessary next step for the patient.
AUDIT- Alcohol Use Disorders Identification Test

What is it?

  • Ten questions, self-administered or through an interview; addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems.
  • Developed by World Health Organization (WHO).
AUDIT Pros and Cons

What are the strengths?

  • Public domain—test and manual are free
  • Validated in multiple settings, including primary care
  • Brief, flexible
  • Focuses on recent alcohol use
  • Consistent with ICD-10  and DSM IV definitions of alcohol dependence, abuse, and harmful alcohol use

Limitations?

  • Does not screen for drug use or abuse, only alcohol

 

DAST (10)

What is it?

  • Shortened version of DAST 28, containing 10 items, completed as self-report or via interview. DAST(10) consists of screening questions for at-risk drug use that parallel the MAST (an alcohol screening instrument).
  • Developed by Addiction Research Foundation, now the Center for Addiction and Mental Health.
  • Yields a quantitative index of problems related to drug misuse.

What are the strengths?

  • Sensitive screening tool for at-risk drug use.

What are the weaknesses?

  • Does not include alcohol use.

 

What is it?

  • Shortened version of the NIDA Modified Assist. The quick screen consists of screening questions for at-risk drug, alcohol and tobacco use.

What are the strengths?

  • Brief. If the patient says “Yes” proceed to NIDA-Modified Assist.
What is Brief Intervention?

Brief Intervention is a brief motivational and awareness-raising intervention given to risky or problematic substance users

What is the Brief Intervention?

There are several models for brief intervention, including the BNI, originally developed by Gail D’Onofrio, M.D., Ed Bernstein, M.D., Judith Bernstein, M.S.N., Ph.D., and Steven Rollnick, Ph.D. 

The BNI is a semistructured interview process based on Motivational Interviewing (MI) that is a proven evidence-based practice and can be completed in 5−15 minutes. 

*Special acknowledgement is made to Drs. Stephen Rollnick, Gail D’Onofrio, and Ed Bernstein  for granting permission to orient participants to the “brief negotiated interview.” 

Step 1: Build Rapport/ Raise the Subject
  • Assure confidentiality.
  • Ask patient's permission to discuss substance use screening results.
  • Gather information about frequency and amount of use.

"Thanks for completing the annual questionnaire we give every patient. Confidentiality is important to us. Are you willing to tell me more about your substance use? What does a typical week look like?" 

Step 2: Provide Feedback/ Make Connections
  • Highlight risks of substance use and recommendations for healthy behavior.
  • Ask about a connection between substance use and current health status.                   

 "We know that substance use (insert patient's screening data) can cause health problems or make existing ones worse such as (insert educational handout/facts). What connection, if any, do you see between your substance use and your current health status?
                           

Step 3: Enhance Motivation
  • Use OARS techniques (Open ended questions, Affirmations, Reflections, Summaries)
  • Explore pros and cons of changing behavior
  • Show ruler and inquire about readiness to change           

"What do you like and what are you concerned about when it comes to your substance use? On a scale of 0-10, how ready are you to cut back/end your use? Why not a higher number?"              

Core MI Skills Commonly Used in Brief Intervention

Open-ended questions

  • Opens the door for exploration
  • How, What, Tell me about…

Affirmations

  • Praise positive behavior
  • Support the person as they describe difficult situations

Reflections

  • “Reflective listening is a way of checking rather than assuming that you know what is meant.” (Miller and Rollnick, 2002)

Summaries

  • Use to begin a session, end a session, transition
Spirit of MI

A way of being with patients that is…

  • Collaborative (not confrontation)
    • Developing a partnership in which the patient’s expertise, perspectives, and input are central to the consultation.
  • Evocative (not education)
    • Motivation for change resides within the patient. Ask key open-ended questions.
  • Respectful of autonomy (not authority)
    • Patient is in charge of his/her choices and thus is responsible for the outcomes.
  • Compassionate
    • Empathy for the experience of others and desire to alleviate the suffering of others.
MI Strategies Most Commonly Used in Brief Intervention
  • Decisional Balance
    • Highlights the individual’s ambivalence (maintaining versus changing a behavior)
    • Leverages the costs versus the benefits
Step 4: Negotiate a Plan
  • Determine goal(s) and discuss next steps.
    • When developing goals utilize SMART objectives:
      • Specific
      • Measurable
      • Achievable
      • Relevant
      • Time limited
  • Summarize session.
  • Schedule follow-up.
  • Thank patient for their time

"This is what I have heard you say (reflect on reasons for change). You have agreed to (state actual amounts of reduction in substance usage). I have included this in your after visit summary as a reference and reminder of your planned goal. Would it be alright if we check in on this goal during our next appointment together?" 

Common Mistakes to Avoid
  • Rushing into “action” and making a treatment referral when the patient isn’t interested or ready.
  • Referring to a program that is full or does not take the patient’s insurance.
  • Not considering pharmacotherapy in support of treatment and recovery.
  • Seeing the patient as “resistant” or “self-sabotaging” instead of having a chronic disease.
Medication-Assisted Treatment (MAT)

Medically Managed Detoxification 

Can be done on an inpatient or outpatient basis depending on the substance use and other bio-psychosocial factors.

  • Medically managed intensive inpatient treatment (COMPLICATED)
    • Also known as inpatient medical withdrawal.
    • For use with alcohol, benzodiazepines, complicated opioid withdrawal (i.e.: with other co-occurring illnesses such as polysubstance dependence, HIV, or other significant medical illness).
  • Medically managed outpatient treatment (UNCOMPLICATED)
    • Also known as outpatient medical withdrawal.
    • For use with opioids (uncomplicated), stimulants (cocaine/ amphetamines).
Medication Assisted Treatment

Detox Meds

  • Methadone (opioid agonist)
  • Clonidine (Alpha agonist, antihypertensive)
  • Benzodiazepines (Ativan)
  • Buprenorphine (Suboxone)

Maintenance Meds

  • Methadone (agonist)
  • Buprenorphine (partial agonist)
  • Buprenorphine/Naloxone (Suboxone, combination agonist/antagonist)
  • Naltrexone (ReVia/Vivitrol, antagonist)

Therapy

  • Cognitive Behavioral Therapy
  • Contingency Management
  • Brief Medication Management
  • Individual & group counseling. 
Summary
  • Validated screening instruments that can be used to evaluate substance use are the AUDIT, DAST, NIDA ASSIST.
  • Providers may be reluctant to use SBIRT due to lack of knowledge of screening instruments, lack of appropriate referrals sources, and concerns of impacting their relationship with their patients.
  • SBIRT can help to identify patients at risk and refer to appropriate treatment, and/or develop a plan to address substance use utilizing community and family resources.

 

Acknowledgements

Denham, S. (2016). Does a Culture of Appalachia Truly Exist? Journal of Transcultural Nursing, 27(2), 94-102.

Dunn, M. S., Behringer, B., Bowers, K. H., & Jessee, R. E. (2010). Evaluation of a Community Approach to Address Substance Abuse in Appalachia. International Quarterly of Community Health Education, 30(2).

Goodman, D. (2013, October 9). The importance of SBIRT in pregnant women and practical tips on how to implement into your workflow. Snuggle ME Webinar Series.

Martin, Linda & Ripley, Bruce. (2011). Cultural Considerations in the Provision of Substance Abuse Treatment for Appalachian Clients.

McGarvey, E. L., Leon-Verdin, M., Killos, L. F., Guterbock, T., & Cohn, W. F. (2011). Health Disparities Between Appalachian and Non-Appalachian Counties in Virginia USA. Journal of Community Health, 36(3), 348–356.

Moran GE, Snyder CM, Noftsinger RF, et al. (October 2017). Implementing medication-assisted treatment for opioid use disorder in rural primary care: environmental scan, volume 1. (Prepared by Westat under Contract Number HHSP 233201500026I, Task Order No.HHSP23337003T). Rockville, MD: Agency for Healthcare Research and Quality

Russ, K. A. (2010). Working with clients of Appalachian culture

SAMHSA (n.d.). MAT Overview

Stauffer, T., Prevention and Treatment of Substance Abuse in Rural Communities Webinar. Rural Prevention and Treatment of Substance Abuse Toolkit PPT. 

Zhang, Z., Infante, A., Meit, M., & English, N. (2008). An Analysis of Mental Health and Substance Abuse Disparities & Access to Treatment Services in the Appalachian Region. Appalachian Regional Commission and National Opinion Research Center.

Raymond P. Miller, EMS Division Chief, City of Crawfordsville, Indiana Fire Department

Through Shared Value
  • Build and sustain a stronger community, promoting social inclusion and breaking cycles of disadvantage
  • Strengthen local economic development
  • Grow and strengthen innovative partnerships with corporate and community stakeholders and across the public sector
  • Demonstrate leadership through collaboration
  • Achieve greater value for money and ensure that this value reflects social, financial, and generational equality.
Not your traditional Fire Department

Our department provides:

  • 911 EMS
  • Tactical EMS
  • Community Paramedicine
  • Fire protection
  • Code enforcement
  • Technical rescue
  • Haz-Mat response
  • Arson origin and cause
  • Education and training on local, State, & Federal levels

Plus over 3,900 calls per year and nearly 300 hrs. of training per FF/per year

Wrapping Services

State Heart Failure Pilot (2017)

Chronic Disease Management (2017)

Prenatal/Postpartum Visits (March 2018)

Falls Program (2019)

Overdose Response (2018)

 

What Can We Offer

Expanded Role, Not Expanded Scope

  • Health & Wellness Programs
  • Health Screening
  • Health Education
  • Immunizations
  • Post Hosp. Admission Monitoring of CHF, COPD, Diabetes, * Pneumonia
  • Access to healthcare options 
What's Different in Crawfordsville

Having A

  • Plan
  • Engaged Community Partners
Collaborative Partners
  • Indiana State Department of Health
  • Franciscan Health - Crawfordsville
  • Montgomery County Community Foundation
  • Purdue Health & Human Sciences
  • Manchester University
  • Montgomery County Health Department, Sheriffs Department, & Courts
  • Indiana University Richard M. Fairbanks School of Public Health
  • Franciscan ACO
  • Wabash College
  • CDC
  • CTSI
  • Qsource

Past Programs

Fall 2018 Online Course Examples of Student Reflection Papers

March 14, 2018 Interview

  • Interview with Shana Merrick, MSW, LSW, CDCA, member of Colerain Township Quick Response Team (QRT)
    Director of Adolescent & Prevention Services, Addiction Services Council, 2828 Vernon Place, Cincinnati, OH 45219
    513-281-7880
    Shanam@addictionservicescouncil.org

March 12, 2018 - Community Paramedicine/Quick Response Team Panel Discussions

One-week Class Content 

Crawfordsville Fire Department
100 South Water Street
Crawfordsville, Indiana 47933
Administrative (765) 362-1277
Direct line (765) 307-2573
Fax (765) 364-5198