There is increasing recognition that outcomes monitoring of patients can provide an important source of information that can serve to upgrade treatment systems.
The primary objective of the Rapid Response Project was to assess the feasibility and acceptability of an outcome measure, the Brief Addiction Monitor (BAM), in VA outpatient substance use disorder (SUD) treatment programs. The project was conducted over an approximately one year time period and consisted of three phases: Phase 1, an initial training and implementation of the BAM; Phase 2, withdrawal of external support to examine the sustainability of BAM use; and Phase 3, assessment of the overall experience with and implementation of impact of the BAM via focus groups with providers and veterans.
Two VAMCs participated in this study, Philadelphia and Minneapolis, with the Philadelphia VAMC serving as the coordinating site. Clinicians administered the BAM to patients beginning new episodes of outpatient SUD specialty care. The BAM is a 17-item, multidimensional questionnaire designed to be administered by clinical staff as an in-person or telephone interview, or to be completed as a patient self-administered questionnaire, for all patients enrolled in outpatient substance abuse programs. It includes both symptom level outcomes as well as functional outcomes.
Phase 1 was the implementation phase. We trained clinical staff to use the BAM at regular intervals with their SUD patients. At minimum, clinicians were encouraged to administer the BAM within two weeks of treatment entry and at minimally one additional follow-up point during the next three months. We provided external facilitation for the implementation process through regularly scheduled meetings with the clinical champion group, in which we monitored BAM usage on a monthly basis, identified barriers to uptake, problem-solved solutions to barriers and developed strategies to increase BAM use. In Phase 2, we withdrew proactive external support from the implementation process to assess the sustainability of the BAM in its absence. In Phase 3, we conducted focus groups with clinical providers and veterans, separately, to gather feedback on the BAM, its utility, and ways that implementation of BAM and the external facilitation provided could be enhanced.
Overall, the BAM was well-received by clinicians and veterans alike. Because of the lag in technological tools we worked with both sites to develop other methods to facilitate remembering to deliver the BAM at treatment entry and at minimally one follow-up point. We observed the BAM administration over a total of about 11 months (between 11/1/2009 through 09/30/2010). Minneapolis incorporated BAM administration into their intake and discharge procedures. They screened and delivered the BAM to 153 patients at treatment entry. Everyone who entered the IOP received a BAM (i.e., 100% at baseline). Of the 153 who received a baseline BAM, 88 (57.5%) received a follow-up BAM. This is mostly related to attrition from the program. A follow-up BAM is not required if a veteran has dropped out. The program in Philadelphia is a larger program. The following are data from their program: 239 of 499 (47.9%) received a baseline BAM; 152 of 499 (30.5%) received a follow-up BAM; 73 of 499 (14.6%) received a baseline AND follow-up BAM. Additional focus groups results indicated the acceptability and enthusiasm for the BAM from both veterans and clinicians alike. Ideas for ways to facilitate BAM administration and to incorporate the BAM into treatment were generated.
While the BAM was well received, it was evident that additional technological tools would be welcomed. For example, both veterans and clinicians were excited about the graphing features we developed using a Microsoft Excel spreadsheet. At present, this requires an additional entry of the BAM into Excel. Clinicians do not have the available time to complete this second data entry. The forthcoming MHA patch would produce similar graphs and might facilitate incorporating the BAM more clearly into treatment.
The benefits to SUD care in the VA could be substantial, as regular administration of the clinical monitor will yield important data on patient processes and outcomes that can be linked with other measures (e.g., treatment attendance, urine toxicology results, etc.) to provide a comprehensive, real-time data source to drive clinical decisions. Specifically, this project will generate recommendations for best practices of BAM implementation at VAMCs nationwide.
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- Drapkin ML. Substance abuse: Diagnosis, comorbidity, and psychopathology. In: Millon T, Blaney RD, editors. Oxford Textbook of Psychopathology (Second ed.). 2nd ed. New York, NY: Oxford University Press; 2008. Chapter 11. 280-297 p.
- Drapkin ML, Oslin DW. Design and Implementation of the Brief Addiction Monitor (BAM) in the VA Substance Abuse Treatment System. Paper presented at: International Society for Biomedical Research on Alcoholism Annual Meeting; 2010 Sep 1; Paris, France.
- Drapkin ML, DePhilippis D, Hagedorn HJ, Kivlahan DR, Oslin D, McKay JR. Brief Addiction Monitor (BAM) in the VA Substance Abuse Treatment System: Implementation and Clinical Applications. Paper presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 28; Baltimore, MD.
- Drapkin ML. Using Interim Monitoring of Alcohol Use and Cravings to inform our understanding of how treatment works and for whom. Paper presented at: Research Society on Alcoholism Annual Scientific Meeting; 2010 Jun 1; San Antonio, TX.
- Drapkin ML, DePhilippis D, Kivlahan DR, Oslin D, Mckay JR. Implementation of the Brief Addiction Monitor (BAM) in the VA substance abuse treatment system. Presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 21; Little Rock, AR.