SBIRT and Public Health Practice: SBIRT and Public Health Practice: The Peer In-Reach Team ModelThe Peer In-Reach Team Model

…bridging the gap between clinical …bridging the gap between clinical medicine and public healthmedicine and public health

Edward Bernstein MD Edward Bernstein MD

Judith Bernstein RNC, PhDJudith Bernstein RNC, PhD

Dept. of Emergency Medicine Dept. of Emergency Medicine Project Assert and the BNI-ART InstituteProject Assert and the BNI-ART Institute NIAAA Youth Alcohol Prevention CenterNIAAA Youth Alcohol Prevention Center

BNI-ART Education FacultyBNI-ART Education Faculty

• Lisa Allee MSW, Boston Medical Center Lisa Allee MSW, Boston Medical Center • Kate Brown, Youth Alcohol Prevention Center, BU School of Kate Brown, Youth Alcohol Prevention Center, BU School of

Public HealthPublic Health• James Feldman MD, Dept. of Emergency Medicine, BU School James Feldman MD, Dept. of Emergency Medicine, BU School

of Medicineof Medicine• William Fernandez MD, Dept. of EM, BU School of MedicineWilliam Fernandez MD, Dept. of EM, BU School of Medicine• Andrea Hall LISW, Boston Medical Center/ BEST Team Andrea Hall LISW, Boston Medical Center/ BEST Team • Patricia Mitchell RN, Dept. of EM, BU School of MedicinePatricia Mitchell RN, Dept. of EM, BU School of Medicine• Melanie Rambaud, Youth Alcohol Prevention Center, BU Melanie Rambaud, Youth Alcohol Prevention Center, BU

School of Public HealthSchool of Public Health• Brenda Rodriquez MBA, BNI-ART Institute, BU School of Brenda Rodriquez MBA, BNI-ART Institute, BU School of

Public Health Public Health • Benjamin Shelton MD, Chief Resident, EM Residency Benjamin Shelton MD, Chief Resident, EM Residency

Program, Boston Medical Center Program, Boston Medical Center • Luann Sweeney RN, Boston Medical CenterLuann Sweeney RN, Boston Medical Center• Ludy Young, Licensed LADC II, Project ASSERT, BMC Ludy Young, Licensed LADC II, Project ASSERT, BMC

SBIRT Workshop SBIRT Workshop

• rationale and evidence for SBIRT

• Project ASSERT collaborative model

• NIAAA screening guidelines

• motivational interviewing principles

• brief negotiation interview & referral skills

• practice SBIRT with case studies

Contending Frameworks, Strategies & PoliciesContending Frameworks, Strategies & Policies

• Is addiction a moral failing/crime Is addiction a moral failing/crime

– best controlled by punishment (jail or drug court mandate) best controlled by punishment (jail or drug court mandate)

• Is addiction a medical problem Is addiction a medical problem

– best treated by acute and chronic disease managementbest treated by acute and chronic disease management

• Is addiction a public health problem requires access to Is addiction a public health problem requires access to

– universal screening universal screening

– brief intervention brief intervention

– specialized treatment specialized treatment

– comprehensive supports for individuals, families and comprehensive supports for individuals, families and

communities (i.e. jobs, mental health services and housing) communities (i.e. jobs, mental health services and housing)

– safeguards for human rightssafeguards for human rights

Why do SBIRT? Why do SBIRT? SBISBIRTRT--Treatment Works! --Treatment Works!

NESARC study 2001-02NESARC study 2001-02

• 35.9% of U.S. adults with alcohol dependence that 35.9% of U.S. adults with alcohol dependence that

began more than one year ago were in full recovery began more than one year ago were in full recovery

(18% abstainers, 17% low risk drinkers)(18% abstainers, 17% low risk drinkers)

• an additional 27% were in partial remission an additional 27% were in partial remission

• 12% were asymptomatic 12% were asymptomatic highhigh riskrisk drinkers drinkers

• only 25%only 25% with alcohol dependence who began with alcohol dependence who began

treatment more than one year ago were still treatment more than one year ago were still

dependent (treatment failures)dependent (treatment failures)

Substance abuse resembles other chronic recurrent Substance abuse resembles other chronic recurrent illnesses: a time for a paradigm shift illnesses: a time for a paradigm shift

• <30% of patients with asthma, HTN, diabetes adhere to <30% of patients with asthma, HTN, diabetes adhere to

prescribed diet and/or behavioral changes, and 50% prescribed diet and/or behavioral changes, and 50%

experience recurrence experience recurrence

• challenges of adherence and recurrence with a substance challenges of adherence and recurrence with a substance

abuse diagnosis are not different from those found in other abuse diagnosis are not different from those found in other

chronic diseases chronic diseases

• substance abuse should be insured, monitored, treated and substance abuse should be insured, monitored, treated and

evaluated like other chronic diseases evaluated like other chronic diseases

McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.

THE TREATMENT GAPTHE TREATMENT GAPPast Year Need for & Receipt of Tx for Illicit Drug/ Past Year Need for & Receipt of Tx for Illicit Drug/ Alcohol Abuse among Persons Aged 12+: 2002-3 Alcohol Abuse among Persons Aged 12+: 2002-3

WHY DOWHY DO S SBIRT: BIRT: SCREENING WIDENS THE NETSCREENING WIDENS THE NET

ABSTAINERS & MILD DRINKERS

(71%)

AT-RISK DRINKERS

(20%)

ABUSE/ DEPENDENCE (8.5%)

Primary Prevention

Brief Intervention

Specialized Treatment

Intersection of Opportunity & Need Intersection of Opportunity & Need An Emergency Department PerspectiveAn Emergency Department Perspective

• 7.6 /111 million ED visits are alcohol attributable 7.6 /111 million ED visits are alcohol attributable

(McDonald, 2004)(McDonald, 2004)

• 31% of urban ED pts 31% of urban ED pts >> 2 CAGE positive 2 CAGE positive

(Bernstein, 1996) (Bernstein, 1996)

• 26% of ED patients high risk/dependent drinkers 26% of ED patients high risk/dependent drinkers

(Academic ED SBIRT (Academic ED SBIRT

Collaborative, 2005)Collaborative, 2005)

WHY DO SWHY DO SBIBIRT?RT?…because brief intervention works!…because brief intervention works!

• Chafetz et al, 1961Chafetz et al, 1961

– (n=200)(n=200)

– 65% of those receiving brief intervention in the MGH 65% of those receiving brief intervention in the MGH

ED showed up for treatment vs 5% of controlsED showed up for treatment vs 5% of controls

– 40% in the intervention group vs 0% in the control 40% in the intervention group vs 0% in the control

group kept 5 appointmentsgroup kept 5 appointments

Establishing treatment relations with alcoholics. J Nerv Ment Dis 1962; 134: 390-410.

Brief Intervention in the Trauma CenterBrief Intervention in the Trauma Center

• 1153 (46%) of 2524 screened positive 1153 (46%) of 2524 screened positive

• 762 were randomized to control or intervention status762 were randomized to control or intervention status

• at 6 months, decreases in both groups (NS) at 6 months, decreases in both groups (NS)

• at 12 monthsat 12 months

– ↓↓ 21.9 drinks per week (intervention) vs 6.7 (control)21.9 drinks per week (intervention) vs 6.7 (control)

• at 3 yearsat 3 years

– 47% greater reduction in serious repeat injuries in 47% greater reduction in serious repeat injuries in

the intervention group vs controls (state dataset) the intervention group vs controls (state dataset)

Gentilello, Rivara et al. Gentilello, Rivara et al. Ann SurgAnn Surg 1999; 230: 473-483 1999; 230: 473-483

Meta-analyses of Motivational Meta-analyses of Motivational InterviewingInterviewing

• small but real effect sizes small but real effect sizes

– Dunn et al, 2001Dunn et al, 2001

– Hettema et al, 2005 (.30 at 1 yr) Hettema et al, 2005 (.30 at 1 yr)

– Vasilaki et al, 2006 (aggregate .18, .60 at 3 mo)Vasilaki et al, 2006 (aggregate .18, .60 at 3 mo)

So if brief intervention works and So if brief intervention works and saves money…saves money…

Why don’t health professionals routinely Why don’t health professionals routinely screen, practice brief intervention, and screen, practice brief intervention, and refer, when indicated, to the substance refer, when indicated, to the substance abuse treatment system?abuse treatment system?

Project ASSERT: Bringing down the barriersProject ASSERT: Bringing down the barriers

A Model for A Model for

Brief Intervention in the EDBrief Intervention in the ED

1993 SAMHSA –CSAT1993 SAMHSA –CSAT

Critical Populations Demonstration GrantCritical Populations Demonstration Grant

Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based

intervention to increase access to primary care, preventive services and the intervention to increase access to primary care, preventive services and the

substance abuse treatment systemsubstance abuse treatment system. Ann Emerg Med. Ann Emerg Med 1997;30:181-189. 1997;30:181-189.

Established with funding from CSAT in 1993 to empower patients to reduce substance abuse and other harmful health and social behaviors, and facilitate ED patient access to primary care, preventive services and substance abuse treatment.

CommunityHealth Promotion

Advocates

Empowerment through Brief Negotiated Interview (Bernstein & Rollnick)

Screening forHealth and

SafetyNeeds

Active Referral Network

for Community Resources

General Medical Setting

Project ASSERT Linkage Strategy Project ASSERT Linkage Strategy

Peer educators provide consultation to Peer educators provide consultation to nurses and physiciansnurses and physicians

…providing empathy and support

……offering resources offering resources

From CSAT Demonstration Grant to From CSAT Demonstration Grant to Boston Medical Center ED Budget Line Item…Boston Medical Center ED Budget Line Item…

RESULTS FROM PROJECT ASSERTRESULTS FROM PROJECT ASSERT

• 17,495 patients received screening and BNI from 2001-200517,495 patients received screening and BNI from 2001-2005

• 16,114 total referrals made to SA treatment, AA/NA, social 16,114 total referrals made to SA treatment, AA/NA, social

service, behavioral health and primary care.service, behavioral health and primary care.

• 5,607 patients sent to detox often by taxi5,607 patients sent to detox often by taxi

• 1608 beds detox unavailable—case management1608 beds detox unavailable—case management

• 1708 SA outpatient1708 SA outpatient

• 1,656 appointments made for primary care1,656 appointments made for primary care

Brief Intervention in the Clinical Setting Reduces Brief Intervention in the Clinical Setting Reduces Cocaine and Heroin Use Cocaine and Heroin Use

Bernstein et al. Bernstein et al. Drug & Alcohol DependenceDrug & Alcohol Dependence, 2004;77:49-59 , 2004;77:49-59

• 23,669 patients screened 23,669 patients screened

• 1175 enrollees (follow-up rate 82%)1175 enrollees (follow-up rate 82%)

• among 778 with positive hair at baseline among 778 with positive hair at baseline

– intervention group more likely to be abstinent at 30 days intervention group more likely to be abstinent at 30 days than the control groupthan the control group

• cocaine alone (22.3% vs 16.9%) cocaine alone (22.3% vs 16.9%)

• heroin alone (40.2% vs 30.6%)heroin alone (40.2% vs 30.6%)

• both drugs (17.4% v s 12.8%), with adjusted OR of both drugs (17.4% v s 12.8%), with adjusted OR of 1.51-1.57 1.51-1.57

– cocaine levels in hair reducedcocaine levels in hair reduced

• 29% for intervention group vs 4% control group29% for intervention group vs 4% control group

THE IMPACT OF ED Provider SBIRT THE IMPACT OF ED Provider SBIRT ON PATIENTS’ ALCOHOL USEON PATIENTS’ ALCOHOL USE

Funded in part by NIAAA R21 AA015123Funded in part by NIAAA R21 AA015123and 14 RO3s AA 01511-14and 14 RO3s AA 01511-14

with collaborative funding from SAMHSAwith collaborative funding from SAMHSA

Academic Emergency Medicine SBIRT CollaborativeAcademic Emergency Medicine SBIRT Collaborative

Boston Medical

New England Med.

Charles Drew Univ.

Univ. of Southern California

Cooper Health

Howard Univ.

Univ. of Michigan.

Denver Health Medical

Univ. of California

Yale Univ.

Univ. of Virginia

Univ. of New Mexico

Rhode Island Hospital

Emory University

Patient Response to SBIRT at 3 month F/U Patient Response to SBIRT at 3 month F/U SummarySummary

• At 3 months, controlling for baseline drinking levels, At 3 months, controlling for baseline drinking levels,

patients receiving the intervention reported patients receiving the intervention reported

– 3.25 fewer ‘typical number of drinks per week’ than 3.25 fewer ‘typical number of drinks per week’ than

controls (controls (BB= -3.25 = -3.25 SESE= 1.16, = 1.16, pp < .05) < .05)

– almost ¾ of a drink less for ‘maximum number of almost ¾ of a drink less for ‘maximum number of

drinks per occasion’ than controls (drinks per occasion’ than controls (BB= -.72 = -.72

SESE= .32, = .32, pp < .05). < .05).

• Benefits of brief intervention were confined to those Benefits of brief intervention were confined to those

with at-risk drinking rather than dependent drinking with at-risk drinking rather than dependent drinking

patterns, as measured by the CAGE.patterns, as measured by the CAGE.

SBIRTSBIRT

The ToolboxThe Toolbox

SBIRT: Why Screen?SBIRT: Why Screen?THE PROBLEM DRINKER (National Gallery)THE PROBLEM DRINKER (National Gallery)

Screening QuestionsScreening Questions

Do you smoke? Do you drink? Do you use drugs?

On average, how many days per week do you drink alcohol ( beer, wine,

liquor )?

On a typical day when you drink, how many drinks do you have?

NIAAA Guidelines (risky drinking):>14 drinks/week for men and >7

drinks per week for women

What is the maximum number of drinks you had on any given occasion

during the last month?

NIAAA Guidelines: >4 for men & >3 for women

Remember that a “standard drink” Remember that a “standard drink” consists of:consists of:

THE ED BRIEF NEGOTIATION THE ED BRIEF NEGOTIATION INTERVIEW INTERVIEW

A toolkit forA toolkit for enhancing motivation for changeenhancing motivation for changein the clinical setting--in the clinical setting--

developed with Stephen Rollnick,1994developed with Stephen Rollnick,1994

Effective communication about alcohol Effective communication about alcohol and drugs….and drugs….

…….approaching the drinking driver .approaching the drinking driver to facilitate behavior changeto facilitate behavior change

from The Emergency Physician and the Problem Drinker D’Onofrio, Bernstein & Bernstein, 1996

NEGOTIATING BEHAVIOR CHANGENEGOTIATING BEHAVIOR CHANGEPrinciples of Good PracticePrinciples of Good Practice

• Respect the autonomy of clients and their choicesRespect the autonomy of clients and their choices

• Set an agenda for change togetherSet an agenda for change together

• Offer information in a neutral, non-personal mannerOffer information in a neutral, non-personal manner

• Make clear from the start that the client is the active Make clear from the start that the client is the active decision makerdecision maker

OTHER PRINCIPLES OF OTHER PRINCIPLES OF MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWING

• Ask open-ended questions.Ask open-ended questions.

• Practice reflective listening to encourage patients to Practice reflective listening to encourage patients to talk about their drinking and the barriers to change. talk about their drinking and the barriers to change.

• Accept resistance as a normal response.Accept resistance as a normal response.

• Avoid confrontation, labeling, stereotyping and forcing Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.patients to accept a label or diagnosis.

NEGOTIATING BEHAVIOR CHANGENEGOTIATING BEHAVIOR CHANGEPrinciples of Good PracticePrinciples of Good Practice

“Motivational interviewing was developed from the

rather simple notion that the way clients are spoken

to about changing addictive behavior affects their

willingness to talk freely about why and how they

might change.”

Stephen Rollnick, PhD

Addiction 2001; 96:1769-70.

THE BRIEF NEGOTIATION INTERVIEWTHE BRIEF NEGOTIATION INTERVIEW

• establish rapport & ask permission to raise subject• provide feedback• enhance motivation

• explore pros and cons • assess readiness to change and sources of resilience• explore discrepancies between actual state & goals

• develop action plan, using strengths/resources• referral to primary care and tx if indicated

1 2 3 4 5 6 7 8 9 10

UNSURE(4 - 7)

NOT READY(1 - 3)

READY(8 - 10)

INTERVENTION ALGORITHM INTERVENTION ALGORITHM 1. Raise subject1. Raise subject

2. Provide feedback2. Provide feedback

Review screen Review screen

Make connection Make connection

For alcohol…For alcohol…Show NIAAA Show NIAAA guidelines & norms guidelines & norms

Hello, I am _____. Would you mind taking a few Hello, I am _____. Would you mind taking a few minutes to talk with me about your use of [X]? minutes to talk with me about your use of [X]? <<PAUSE and LISTEN>> <<PAUSE and LISTEN>> Before we start, could you tell me a little about Before we start, could you tell me a little about yourself and your goals (or what’s important to yourself and your goals (or what’s important to you?)you?)

From what I understand you are using [insert From what I understand you are using [insert screening data]… We know that drinking above screening data]… We know that drinking above certain levels and/or use of illicit drugs can cause certain levels and/or use of illicit drugs can cause problems, such as [insert medical info]… problems, such as [insert medical info]… I am concerned about your use of [X]. I am concerned about your use of [X].

What connection (if any) do you see between your What connection (if any) do you see between your use of [X] and this ED visit? use of [X] and this ED visit? If pt sees connection: reiterate what pt has said. If pt sees connection: reiterate what pt has said. If pt does not see connection, suggest one, using If pt does not see connection, suggest one, using medical info (but don’t confront). medical info (but don’t confront).

These are what we consider the upper limits of low These are what we consider the upper limits of low risk drinking for your age and sex. By low risk we risk drinking for your age and sex. By low risk we mean that you would be less likely to experience mean that you would be less likely to experience illness or injury if you stayed within these illness or injury if you stayed within these guidelines. guidelines.

3. Enhance motivation3. Enhance motivation Explore Pros and Cons Explore Pros and Cons

Use reflective listening Use reflective listening

Readiness to change Readiness to change

Reinforce positivesReinforce positivesDevelop discrepancyDevelop discrepancy

between ideal between ideal and and present selfpresent self

Ask pros and cons. Help me to understand Ask pros and cons. Help me to understand what you enjoy about [X]? what you enjoy about [X]?

<<PAUSE AND LISTEN>> <<PAUSE AND LISTEN>>

Now tell me what you enjoy less about [X] Now tell me what you enjoy less about [X] or regret about your use.or regret about your use.

<<PAUSE AND LISTEN>> <<PAUSE AND LISTEN>> On the one hand you said… On the one hand you said… <<RESTATE PROS>> <<RESTATE PROS>> On the other hand you said…. On the other hand you said…. <<RESTATE CONS>> <<RESTATE CONS>>

So tell me, where does this leave you? So tell me, where does this leave you? [show readiness ruler] [show readiness ruler]

On a scale from 1-10, how ready are you On a scale from 1-10, how ready are you to change any aspect of your use of to change any aspect of your use of [X]? [X]?

Ask: Why did you choose that number Ask: Why did you choose that number

and not a lower one like a 1 or a 2? and not a lower one like a 1 or a 2? Other reasons for change? How does Other reasons for change? How does this fit with where you see yourself in this fit with where you see yourself in the future?the future?

4. Negotiate & advise4. Negotiate & advise

Negotiate goal Negotiate goal

Benefits of changeBenefits of change

Reinforce resilience /Reinforce resilience /resourcesresources

Summarize Summarize

Provide handouts Provide handouts

Suggest PC f/u Suggest PC f/u

Thank patient Thank patient

What’s the next step? What’s the next step?

What do you think you can do to stay What do you think you can do to stay healthy and safe? healthy and safe?

If you make these changes what do you If you make these changes what do you think might happen?think might happen?

What have you succeeded in changing in What have you succeeded in changing in the past? How? Could you use these the past? How? Could you use these methods to help you with the challenges methods to help you with the challenges of changing?of changing?

This is what I’ve heard you say…Here’s an This is what I’ve heard you say…Here’s an agreement I would like you to fill out, agreement I would like you to fill out, reinforcing your new goals. This is reinforcing your new goals. This is really an agreement between you and really an agreement between you and yourself. yourself.

Provide agreement and information sheet Provide agreement and information sheet

Suggest Primary Care f/u to Suggest Primary Care f/u to discuss/support carrying out plan discuss/support carrying out plan

Thank patient for his/her timeThank patient for his/her time

Applying the algorithm…Applying the algorithm…

Getting to ‘yes’ with Getting to ‘yes’ with

a high risk drinkera high risk drinker

Provider: Clara Safi, NPProvider: Clara Safi, NP

www.ed.bmc.org/sbirtwww.ed.bmc.org/sbirt

Connecting drinking & Reason for Visit Connecting drinking & Reason for Visit

• This is the patient’s chance to name the problem.This is the patient’s chance to name the problem.

• If there is resistance or lack of awareness of a connection, the If there is resistance or lack of awareness of a connection, the

provider can help the patient see the connection.provider can help the patient see the connection.

• Listen carefully for the patient’s own concerns to make the link.Listen carefully for the patient’s own concerns to make the link.

• Use open ended questions to explore:Use open ended questions to explore:

– What would make this a problem for you?What would make this a problem for you?

– How might you prevent that from happening?How might you prevent that from happening?

– Have you ever done anything you wished you hadn’t while Have you ever done anything you wished you hadn’t while

drinking?drinking?

• Give feedback empathetically, with no shame or blame.Give feedback empathetically, with no shame or blame.

1 2 3 4 5 6 7 8 9 10

ASSESSING READINESS TO CHANGE

On a scale of 1-10, ten meaning ‘most ready’ and one ‘least ready’, please mark on the ruler where you are now on your readiness to change your use of alcohol and/ or drugs?

You marked five, which indicates you are fifty percent ready to make a change, so tell me, why didn’t you mark a lower number like a one or two?

The pros and cons in action….The pros and cons in action….

Provider: Ludy Young, Health Promotion AdvocateProvider: Ludy Young, Health Promotion Advocate

at National Alcohol Screening Dayat National Alcohol Screening Day

www.ed.bmc.org/sbirtwww.ed.bmc.org/sbirt

Exploring the Pros and ConsExploring the Pros and Cons

• exploring the pros and cons can help you understand exploring the pros and cons can help you understand where the patient is coming from and obstacles to change where the patient is coming from and obstacles to change

• pros and cons strategypros and cons strategy

– ask, “What do you like about your use of [X]?” ask, “What do you like about your use of [X]?”

– acknowledge that you have heard what they sayacknowledge that you have heard what they say

– elicit statements about consequences by asking elicit statements about consequences by asking

• ““What do you like less or regret about your use?”What do you like less or regret about your use?”

– repeat and affirm statements that lead to changerepeat and affirm statements that lead to change

– summarize briefly: on the one hand you said.., and on summarize briefly: on the one hand you said.., and on the other you said…. the other you said….

– ask, “Where does that leave you?” On a scale of 1-10, ask, “Where does that leave you?” On a scale of 1-10, how ready are you to make some changes?how ready are you to make some changes?

Provider advice and negotiation with Provider advice and negotiation with the dependent drinker….the dependent drinker….

Provider: Gail D’Onofrio, MDProvider: Gail D’Onofrio, MD

www.ed.bmc.org/sbirtwww.ed.bmc.org/sbirt

THE ROLE OF PROVIDER ADVICETHE ROLE OF PROVIDER ADVICE

• meet people where they are at meet people where they are at

• timing is important—the patient should feel heard timing is important—the patient should feel heard

and respected and respected beforebefore the physician weighs in the physician weighs in

• conversational style matters—advice should be conversational style matters—advice should be

brief, and non-judgmentalbrief, and non-judgmental

• advice should be based on fact and weave in advice should be based on fact and weave in

medical eventsmedical events

IN NEGOTIATING A PLAN, EXPLORE….IN NEGOTIATING A PLAN, EXPLORE….

• previous strengths, resources and successesprevious strengths, resources and successes

– ““Have you stopped drinking/using drugs before?”Have you stopped drinking/using drugs before?”

– ““What personal strengths allowed you to do it?”What personal strengths allowed you to do it?”

– ““Who helped you and what did you do?” Who helped you and what did you do?”

oror

– ““Have you made other kinds of changes Have you made other kinds of changes

successfully in the past?” successfully in the past?”

– ““How did you accomplish these things?”How did you accomplish these things?”

Developing and Using a Referral NetworkDeveloping and Using a Referral Network

• Provider expectations: setting realistic goals Provider expectations: setting realistic goals

for change in a chronic diseasefor change in a chronic disease

• http://findtreatment.samhsa.govhttp://findtreatment.samhsa.gov

• www.ed.bmc.org/sbirtwww.ed.bmc.org/sbirt