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APPENDIX B: MEDICAL MANAGEMENT TRAINING AND SESSION

ADHERENCE CHECKLISTS

Form

B–1    MM Practitioner Qualifications, Training, and Supervision

Adherence Checklists To Be Used at the MM Initial Session

B–2    Instructions for Use of MM Treatment Adherence Checklists

B–3    MM Initial Session, Advance Preparation: Review Clinician Report Information Checklist and Prepare Chart Material Checklist

B–4    MM Initial Session: Introduction and Feedback Checklists

B–5    MM Initial Session: Medication Compliance Checklist

B–6    MM Initial Session: Wrap-Up Checklist

B–7    Brief Checklist for MM Initial Session

Adherence Checklists To Be Used at MM Followup Sessions

B–8    MM Followup Sessions: Part 1 Checklist

Checklists To Be Used Depending on Patient Status

B–9    Abstinent and Medication Compliant

B–10    Nonabstinent and Medication Compliant

B–11    Abstinent and Medication Noncompliant

B–12    Nonabstinent and Medication Noncompliant

B–13    Brief Checklist for MM Followup Sessions

B–14    Brief Checklist for Medical Attention Visits

 

Form B–1

MM Practitioner Qualifications, Training, and Supervision

Practitioner Qualifications

 

To be an MM practitioner, the person should be medically trained and have a working knowledge of the following areas: the pharmacotherapies to be used, medication compliance, and alcohol dependence. Prior education on substance dependence and/or exposure to substance abuse patients is important, but the MM practitioner is not required to be a specialist in counseling, therapy, or substance abuse treatment. Depending upon the medical training the MM practitioner has, he/she may need supervision and should have access to physician consultation about medication side effects, changes in dosing, significant lab values, and any medical concerns.

 

In the COMBINE study, pharmacists, physicians, nurse practitioners, physician’s assistants, and nurses delivered the MM intervention. MM clinicians were required to be certified in providing the MM intervention prior to giving treatment in the main study. There was on-site supervision for the duration of the study. Also, each site regularly submitted audiotapes of MM sessions the practitioners conducted, and a centralized intervention-training center for COMBINE at the University of New Mexico provided written feedback on their delivery.

Practitioner Training

 

Besides staying focused on the medical and health-related issues, the MM practitioner needs to express warmth and support while conveying his/her expertise and knowledge (i.e., have a good bedside manner). To this end, the MM practitioner undergoes training comprising the following three segments:

 

1. Preparation. The practitioner needs to learn and understand the general and treatment-specific MM procedures, documentation requirements, and overall purpose of the intervention.

2. Practice. The practitioner needs to practice delivering the MM intervention to a variety of clinical cases. In COMBINE, the practitioners also trained by using two scenarios that were based on typical cases. Each of the case scenarios included an initial visit and four followup visits. These role-playing episodes ensured that the practitioners had experience coping with patients who had side effect issues, had problems with medication compliance, were resistant to treatment, and had problems with maintaining abstinence; the episodes also ensured the practitioners had opportunities for providing support for patients who were doing well.

3. Certification. To be certified to provide MM intervention, the practitioner must meet standards showing that he/she has mastered the style (e.g., warmth, informative, authoritative [see the six dimensions in the “Practitioner Supervision” section following]) and the skills to complete the key elements of the intervention that are consistent with the MM manual.

Practitioner Supervision

 

Ideally, the MM practitioner should receive ongoing clinical supervision. Supervisors can accomplish this by audiotaping the practitioner in session with patients, then reviewing tapes either selected at random or selected to address a specific issue. A coding system was developed in COMBINE to monitor MM treatment adherence; the clinical supervisor can also use it for providing feedback to the MM practitioner. The coding system consists of the six dimensions outlined below. Each dimension is rated on a 1-to-7 Likert scale, with 7 representing an exemplary performance on that dimension. The acceptable scoring range on any of the dimensions is 5 through 7, with 6 considered the target for overall proficiency.

The Six Dimensions of the COMBINE Coding System

1. Informative
The practitioner communicates correct information to the patient appropriately and effectively and in a way that it is clear, concise, and understandable. This includes educational information (e.g., effects of alcohol, how the liver functions, expectations for treatment participation, importance of medication compliance, managing side effects), the patient’s clinical feedback (e.g., lab results, consequences of drinking, dependence criteria), and the practitioner’s advice (i.e., recommendations for abstinence, suggestions for strategies to increase medication compliance, and encouragement for AA or other mutual-support group attendance). Practitioners receive lower ratings for providing inaccurate, inappropriate, misleading, or unclear information. Practitioners receive higher ratings for providing exceptionally clear and well-timed information.

2. Direction

The practitioner maintains appropriate control of the session and follows the recommended sequencing. That is, the practitioner provides appropriate structure, moves smoothly through treatment procedures, and brings the patient back on task when conversation drifts away to tangential topics. Practitioners receive lower ratings when the overall flow of the session is disjointed, confusing, or lacks cohesion. Practitioners receive higher ratings when the direction of the session moves in a logical flow that builds a case for the treatment.
3. Authoritativeness
The practitioner conveys his/her professionalism, expertise, and confidence in his/her competence to provide effective treatment to his/her patients. The practitioner stands firm in his/her vision of the overall goal of abstinence and advocates for medication compliance, expresses optimism for his/her patient’s recovery, and offers straightforward suggestions and strategies that are useful and appropriate. Practitioners receive lower ratings when they lack a sense of expertise, consistently defer to the patient or other professionals, or collude with the patient in an inappropriate manner. Practitioners receive higher ratings when they are able to convey a vision of recovery, even in the face of discouraging news from the patient.

4. Warmth

The practitioner comes across as warm, friendly, engaged, compassionate, helpful, and concerned. Practitioners receive lower ratings when they are judgmental or appear cold and disinterested. Practitioners receive higher ratings when they respond consistently and genuinely in providing praise, support, or concern.

5. Following Protocol Requirements
The practitioner follows the protocol when he/she delivers treatment procedures as prescribed in the MM manual. The adherence checklists are used to track this dimension (see Appendix B for checklists). Ratings are decreased in 0.5-point increments for key components the practitioner does not deliver. Ratings are increased in the same 0.5-point increments if the practitioner does an exceptional job of covering those key components.
6. Avoiding Nonprotocol Items
The practitioner should avoid doing things that are not a part of the MM intervention or protocol. In research trials, nonprotocol events should be strictly avoided. In clinical settings, nonprotocol procedures may or may not be allowable within the MM practitioner’s overall approach, depending upon the practitioner’s training and the treatment plan. To this end, the MM practitioner should be clear with the patient about what non-MM elements may or may not occur during MM visits. Practitioners receive lower ratings when they provide some form of psychotherapy or counseling beyond the expectations of the MM intervention. They may also receive lower ratings when there are excessive interruptions during the session (e.g., phone calls, knocks on the door). Practitioners receive higher ratings when they are able to confine the content of the session to the elements that are part of the MM intervention, as specified in the MM manual.

Considerations for Research

 

The MM intervention, originally designed in a research setting, can easily be used in other research settings. It is important to create a standard intervention delivery, which can be achieved with a well-developed training and certification process for practitioners. In addition, ongoing monitoring of practitioner performance through observation (primarily audiorecording and coding of sessions), feedback to practitioners, and supervision/coaching/training to resolve performance issues is essential to maintaining intervention standards. Procedures to “decertify” an individual practitioner and a mechanism for recertification should be in place for situations in which the practitioner’s performance levels fall below the acceptable range (e.g., if dimension ratings consistently fall below 5).

Common Pitfalls

 

As the result of coding sessions and reviewing practitioner performance, some common problem areas have emerged. These are listed with suggestions for addressing them.

 

Providing patient feedback.
Practitioners incorrectly use the feedback portion of the initial MM visit as a way to verify assessment data rather than as a time to proactively educate patients about their disorder and motivate them for treatment. For example, a practitioner may ask the patient to answer the same questions he/she answered on an assessment sheet or affirm his/her earlier responses. This can lead to disagreements about the responses, which decreases the practitioner’s authoritative position. The most effective way of delivering the assessment information at the initial MM visit is to present a statement that explains the source of the information and then to immediately present the information in the same way that medical results would typically be communicated to patients.

 

Delivering a logical and coherent intervention.

There is structure built into the MM intervention for both the initial and followup visits that is designed to build and maintain a strong case for both abstinence and medication compliance. The recommended flow ensures a logical progression toward the overall goals of the intervention. Practitioners often struggle with adhering to that flow. The result is a lack of cohesion that is often confusing to the patient and may reduce the impact of the intervention.

Maintaining a limited focus. This intervention is designed to be used in a private practice setting as well as in a medical clinic. Depending upon the situation, a practitioner may be expected to confine the session to MM principles and not venture into psychotherapy or extended problem-solving. It is important for the MM practitioner to determine if the patient’s multiple problems are primarily a result of excessive drinking. After successful treatment, many patients find that some of their psychological and social problems dissipate with abstinence. However, this is not always the case. Sometimes a patient needs more specialized services, and either the MM practitioner will provide them or the MM practitioner will make a referral and work collaboratively with another specialized professional. That is, some practitioners may have training and experience that includes addiction counseling–based interventions. Clearly, if counseling or other therapies are added to MM visits, this will change the amount of time needed as well as the nature of the MM intervention. However, many practitioners will not have this expertise, and they may need strategies for confining MM visits to a limited focus.

 

Length of MM visits. The length of the MM visits will be determined largely by the setting in which they are conducted. The availability of support staff to complete portions of the MM visit, such as taking vital signs, affects how much time a practitioner needs to spend with a patient. In a research setting, the time may also be affected by the amount and type of data collected during the visit. MM visits that are less than 15 minutes are too short to cover all the key elements in the MM intervention. These visits often seem rushed and can convey a lack of caring by the practitioner. MM visits that are longer than 25 minutes may happen when the patient has complicated medical/medication problems. However, most visits that last longer than 25 minutes either suffer from a lack of structure and focus on the part of the practitioner or include various types of nonprotocol items (see “The Six Dimensions of the COMBINE Coding System” section).

Promoting abstinence. Although the MM intervention is abstinence-based, taking too strong a stand on this may result in the loss of some patients. Practitioners need to maintain their relationship with patients, staying “on their side” while at the same time making recommendations for abstinence. Sometimes, framing the progress of the patient in relationship to abstinence is a way for a practitioner to be successful at negotiating abstinence without becoming pushy or judgmental. Nonetheless, this is always a formidable task for the practitioner.

 

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Form B–2

Instructions for Use of MM Treatment Adherence Checklists

 

MM treatment adherence checklists are intended to serve as guidelines for the MM practitioner to follow in conducting initial and followup sessions. They are also intended to be the means of tracking practitioner adherence to MM treatment as outlined in the MM manual.

 

The adherence checklists cover all phases of MM intervention. Each checklist includes space to mark the week of treatment and the date of treatment. The practitioner should use the checklist appropriate to the session he/she is conducting and only check items that he/she covers in each session.

 

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Form B–3

 

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

MM Initial Session, Advance Preparation

Review Clinician Report Form Information Checklist

      Medical Information: Double-check lab report, and record any other drinking-related medical symptoms as noted on physical examination or lab reports.
      Alcohol Use: Record the number of drinking days per week and average number of drinks per drinking day.
      Consequences of Drinking: Record one to three negative consequences acknowledged by the patient. Select items with the highest score or impact to discuss as examples of drinking-related problems.
      Diagnostic Information: Review symptoms of alcohol dependence.

Prepare Chart Material Checklist

      1. Vital Signs and BAC (Form A–2)
 2. Concurrent Medications (Form A–3)
 3. Modified SAFTEE (Form A–7)
 4. Menstrual Calendar (Form A–10) (put NA, if not applicable)
 5. Naltrexone Information Sheet: Patient Version (Form C–1), Acamprosate Information Sheet (Form C–2), Medication Instructions Summary (Form C–3)
 6. Medication Compliance Plan (Form A–13)
 7. Support group materials
 8. Medical Emergency Cards (Form C–6)
 9. Patient Instructions for Managing Side Effects (Form C–5)
 10. Determine if the patient is seeing a second clinician for therapy.

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Form B–4

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

MM Initial Session: Introduction Checklist

      1. Introduce yourself and your role.
      2. Take vital signs, BAC, and weigh patient. (If done by other staff, note NA.)
 3. Give structuring statement.
 4. Go over Concurrent Medications form (Form A–3) (wherever appropriate in the session); ask specifically about NSAID use.
 5. Administer the Modified SAFTEE (Form A–7) wherever appropriate in the session. For women, get birth control information and complete the Menstrual Calendar (Form A–10).

 

MM Initial Session: Feedback Checklist

      1. Give structuring statement. [Explain four areas you will cover: physical effects, amount of drinking, drinking-related problems, and symptoms of alcohol dependence.]
      2. Explain briefly what the liver does, and how alcohol can affect it (i.e., fat deposits, inflammation, scarring, and destruction of liver).
 3. Review blood pressure reading, liver enzymes, any abnormal lab values, and other drinking-related medical symptoms. [State your medical opinion of how alcohol is affecting the patient physically.]
 4. Review drinking pattern date (from TLFB or Form 90). [For example, on average, patient has been drinking ___ days per week, and on days when patient drinks, he/she has had an average of ___ drinks. State that this level of drinking has negative impact on patient.]
 5. Review consequences of drinking by selecting three good examples of items marked on the DrInC. [State your impression of the patient’s negative consequences.]
 6. Review the specific dependence criteria that the patient met. [Repeat that together these symptoms confirm alcohol dependence and that this diagnosis applies to the patient.]
 7. Pull together the physical, drinking, problem, and dependence feedback and draw your conclusions about problem severity.
 8. Make your medical recommendation that the patient stop drinking.
 9. If the patient resists long-term abstention, recommend a trial period of abstinence. [Put NA if patient already agreed to abstinence above.]

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Form B–5

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

MM Initial Session: Medication Compliance Checklist

      1. Provide rationale for pharmacotherapy. Explain that these medications have been found to work to help people to maintain abstinence (e.g., they seem to reduce the urge or desire to drink).
      2. Distinguish from other types of drugs (disulfiram [Antabuse]), addicting drugs, medications used in detoxification. Address any misconceptions.
 3. Provide medication information sheets (Forms C–1, C–2, C–3).
 4. Explain what is known about how the medication works. [Explain possible side effects and their likelihood. Explain that these medications take some time to take effect—don’t expect to feel immediate effects.]
 5. Administer Modified SAFTEE (Form A–7) prior to giving the patient initial dose of medication.
 6. Observe patient take the morning dose (allow 20 minutes to watch for negative reaction).

 

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7. Explain dosing (check separately):

a. Typical dose is four pills in morning, two pills at midday, two pills in evening.
b. Pills can be taken with food if desired.
c. Explain what to do about missed doses, lost medication, and so on.
d. There must be at least 2 hours between doses.
e. Pills cannot be crushed.
f. Give patient handout Patient Instructions for Managing Side Effects (Form C– 5).

 8. Explain emergency procedures and provide emergency contact cards (Form C–6) (one for patient and one for significant other).
 9. Provide basic rationale for compliance and monitoring. [Taking the dosage as prescribed increases the effectiveness of medications. Advise the patient at each MM session that you will be following up on medications taken.]

 

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10. Medication Compliance Plan (Form A–13): Review history of taking pills (check separately):

a. Discuss possible problems in taking medications properly, where applicable.
b. Decide level of need for plan for pill-taking.
c. Decide on strategies to remember pills.
d. Record the personal medication compliance plan.
e. Tell patient that the plan will be revised, if needed.

 11. Advise patient to return blister cards at each visit, even if all pills are not taken.

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Form B–6

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

MM Initial Session: Wrap-Up Checklist

      1. Summarize diagnosis briefly and recommend abstinence.
      2. Recommend mutual-support groups as an aid to change.
 3. Provide literature on local mutual-support groups. [Problem-solve obstacles to attendance as necessary.]
 4. If patient is also seeing a therapist, support the patient in his/her effort.
 5. Document the number of pills prescribed on the Pill Count form (Form A–14).
 6. Schedule next session.
 7. Advise patient that you will call in 3 days.

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Form B–7

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

Brief Checklist for MM Initial Session

_____ Introduce yourself and your role, check vital signs, give overview and timeline of intervention.

_____ Conduct baseline Modified SAFTEE (Form A–7) (reference last 90 days).

_____ Complete Concurrent Medications form (Form A–3) (reference last 90 days).

_____ Complete Menstrual Calendar (Form A–10) (indicate NA if not appropriate).

_____ Provide feedback from initial evaluation (Clinician Report [Form A–1]) (vital signs, lab results, drinking-related symptoms, drinking pattern and consequences, dependence criteria).

_____ Provide information (importance of the liver and how it works, effects of alcohol, diagnostic information, reasons for abstinence).

_____ Give professional opinion about severity of the problem.

_____ Recommend abstinence.

_____ Ask patient for commitment to abstinence. If patient is unwilling to commit to long-term abstinence, restate the rationale for and seek agreement to abstinence for duration of treatment.

_____ Explain purpose and function of medications, and provide information sheets on naltrexone and acamprosate (Forms C–1 and C–2).

_____ Discuss likelihood of side effects and give Patient Instructions for Managing Side Effects (Form C–5).

_____ Explain proper medication use (extra doses, 2 hours between doses, don’t crush, can take with food, morning dose always first) and give first dose (allow 20 minutes for observation).

_____ Give Medical Emergency Cards (Form C–6) and explain emergency procedures.

_____ Provide rationale for and complete Medication Compliance Plan (Form A–13).

_____ Briefly review diagnosis, recommendation, and plan.

_____ Encourage AA/mutual-support group attendance; give list of local meetings.

_____ Schedule next visit and discuss Day 3 phone call (Day 3 Clinician Phone Contact form [Form A–15]).

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Form B–8

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

MM Followup Sessions: Part 1 Checklist

      1. Take patient’s vital signs, BAC, and weigh patient (if done by other staff, note NA).
      2. Ask the patient how he/she has been since the last visit, what was difficult, what went well. [Note: If the patient has not done any drinking since the last visit, ask specific questions, such as, “How were you able to keep from drinking?”]

  

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3. Medical Status

a. Record concurrent medication use on the Concurrent Medications form (Form A–3) (ask specifically about NSAID use).
b. Administer Modified SAFTEE (Form A–7).
c. Complete Menstrual Calendar (Form A–10) and get current birth control information (put NA if applicable).
d. Complete Serious Adverse Event Report (Form A–11) if necessary.
e. Report current laboratory results, when appropriate.

 4. Ask whether patient returned blister card. Praise patient for medications taken. [Examine the blister card and ask if the medications missing were actually taken.]
 5. Inquire about any skipped doses (even if pills appear taken). Query relation of skipped doses to any drinking.

 

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6. Determine what treatment scenario is applicable, check which applies, and complete appropriate Followup Visit Checklists:

Abstinent and Medication Compliant (Form B–9)
Nonabstinent and Medication Compliant (Form B–10)
Abstinent and Medication Noncompliant (Form B–11)
Nonabstinent and Medication Noncompliant (Form B–12)

 7. If patient is in therapy with another clinician, ask about it.
 8. Document the number of pills prescribed on the Pill Count sheet (Form A–14).

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Form B–9

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

Abstinent and Medication Compliant

       1. Reinforce the patient’s ability to stick to the plan. Praise progress. Ask how the patient did it.
      2. Remind the patient it is necessary to continue to take all medications and attend sessions until the end of treatment.
      3. Review benefits of abstinence.
 4. Provide support.
 5. Reinforce or inquire about AA or other mutual-support group attendance. Note here as “not willing to consider” (“NWTC”) if the patient is adamantly opposed.
 6. Conclude visit on a positive note, with general encouragement and praise.

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Form B–10

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

Nonabstinent and Medication Compliant

      1. Reinforce the patient for taking medication.
      2. Review with the patient the Clinician Report (Form A–1) to remind the patient why he/she sought treatment.
      3. Praise small steps of progress.
 4. Review the benefits of abstinence (in general terms).
 5. Remind the patient that medications work gradually over time.
 6. Review the benefits of other aspects of treatment (other therapy/mutual-support groups).
 7. Reinforce or inquire about AA or other mutual-support group attendance. Note here as “not willing to consider” (“NWTC”) if patient is adamantly opposed.
 8. Conclude visit on a positive note, with general encouragement and praise.

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Form B–11

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

Abstinent and Medication Noncompliant

 1. Reinforce the patient for remaining abstinent.
 2. Review general benefits of abstinence, and how medications help abstinence.
 3. Probe why the patient did not take medications regularly; problem-solve.
 4. Emphasize that taking medications faithfully can improve chances of staying abstinent.

 

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5. Return to Medication Compliance Plan (Form A–13).

a. Review common reasons for noncompliance (Section B on Form A–13).
b. Reconstruct Medication Compliance Plan.

 6. Reinforce or inquire about AA or other mutual-support group attendance. Note here as “not willing to consider” (“NWTC”) if patient is adamantly opposed.
 7. Conclude visit on a positive note, with general encouragement and praise.

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Form B–12

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

Nonabstinent and Medication Noncompliant

 1. Reinforce the patient for any progress you see (including coming in for session).
 2. Review the benefits of abstinence, and review reasons for stopping (from initial session).
 3. Encourage the patient to give treatment a chance.
 4. Emphasize that taking medication faithfully can improve chances of staying abstinent.

 

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5. Return to Medication Compliance Plan (Form A–13).

a. Review common reasons for noncompliance (Section B on Form A–13).
b. Reconstruct Medication Compliance Plan.

 

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6. If patient is no longer motivated to stop or reduce drinking, then:

a. Remind the patient of the reasons for stopping; refer to Clinician Report form Form A–1).
b. Remind the patient of the benefits of abstinence.
c. Discuss AA attendance.
d. Discuss other aspects of treatment that might help increase abstinence.

 7. Reinforce or inquire about AA or other mutual-support group attendance. Note here as “not willing to consider” (“NWTC”) if patient is adamantly opposed.
 8. Conclude visit on a positive note, with general encouragement and optimism.

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Form B–13

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

Brief Checklist for MM Followup Sessions

_____ Review Vital Signs and BAC (Form A–2) with patient.

_____ Conduct brief assessment of drinking, medication compliance, and general function.

_____ Complete Concurrent Medication form (Form A–3).

_____ Conduct Modified SAFTEE (reference time since last visit) (Form A–7) (complete Serious Adverse Event Report [Form A–11] as needed).

_____ Complete Menstrual Calendar (Form A–10) (indicate NA if not applicable).

_____ Review new lab results if appropriate; compare with earlier results.

_____ Check blister card for missed doses or trouble with medication compliance (revise Medication Compliance Plan [Form A–13], as necessary).

_____ Reinforce and praise progress.

Session Type

__1. Abstinent/medication compliant

__2. Nonabstinent/medication compliant

__3. Abstinent/nonmedication compliant

__4. Nonabstinent/nonmedication compliant

Options for Review and Problem-Solving; Opportunities for Praise and Reinforcement

_____ Benefits of abstinence

_____ Patient’s reasons for seeking treatment

_____ How the medications work

_____ Importance of medication compliance

_____ Suggestions of strategies for abstaining from alcohol

_____ Suggestions for improving medication compliance

Wrap-Up

_____ Inquire about and encourage AA/mutual-support group attendance.

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Form B–14

PATIENT ID #______________ WEEK #_________ MM CLINICIAN ID #________ DATE___________

Brief Checklist for Medical Attention Visits

_____ Review Vital Signs and BAC (Form A–2) with patient.

_____ Conduct brief assessment of drinking and general function.

_____ Complete Concurrent Medication form (Form A–3). Ask specifically about NSAIDs.

_____ Conduct Modified SAFTEE (Form A–7) (reference time since last visit; complete Serious Adverse Event Report [Form A–11] as needed).

_____ Complete Menstrual Calendar (Form A–10) (indicate NA if not applicable).

_____ Review new lab results if appropriate; compare with earlier results.

Options for Review and Problem-Solving; Opportunities for Praise and Reinforcement

_____ Benefits of abstinence

_____ Patient’s reasons for seeking treatment

_____ Suggestions of strategies for abstaining from alcohol

_____ Reinforce need to continue coming to MA/MM appointments

_____ Reinforce and praise progress

_____ Plans for resuming the medications (if appropriate).

Wrap-Up

_____ Inquire about and encourage AA/mutual-support group attendance.

_____ Provide support.

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