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Sherry Szczuka DSAMH: Okay?
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amy rust- Attack Addiction: Yes.
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Sherry Szczuka DSAMH: Alright.
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Sherry Szczuka DSAMH: Great, outstanding, and I believe when we’re done the meeting, the slide deck will be available to all of you. And as we always ask, because you are new, this is your first TA session, we’d like our participants and our providers to be on camera.
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Sherry Szczuka DSAMH: We also, if you could please rename yourselves and put your organization name next to your name. It’s the three ellipticals in your picture.
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Sherry Szczuka DSAMH: And you can abbreviate, we’re okay with that.
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Sherry Szczuka DSAMH: And we are going to, move through this
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Sherry Szczuka DSAMH: presentation, and we are going to ask you questions, we’re going to ask for some participation, and let me start with saying, welcome to the first TA session for SOR 4.
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Sherry Szczuka DSAMH: You are all recipients of SBIRT. We, the more you engage with us, the more meaningful the presentation will be, not just today, but for future events. We ask that you,
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Sherry Szczuka DSAMH: Kindly participate, ask questions. If you’re not comfortable asking a question, drop it in the chat for us, and we’ll be glad to answer it, where it’s appropriate.
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Sherry Szczuka DSAMH: And if we can, go to the next slide, please.
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Sherry Szczuka DSAMH: And my name is Sherry Strucka, I’m with the DSAM team, and for most of you, you should have seen me at either a kickoff, or an informational webinar, or at the SOR conference.
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Sherry Szczuka DSAMH: I am one of the members on the team here. We also have your program integrity specialist on the call. We also have BBS on the call, which is one of our consultants that we contract with to do technical assistance with us.
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Sherry Szczuka DSAMH: And then we have Amy Shanahan, who will be doing the majority of the presentation, and is the subject matter expert with all things SBIRP.
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Sherry Szczuka DSAMH: So, next slide, please.
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Sherry Szczuka DSAMH: Again, you guys already have done that, so we’ll go to the next slide, but welcome again.
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Sherry Szczuka DSAMH: And, our agenda for today will be… we’ve already got through the first bullet, we’re going to do a very brief overview of SOR 4. We call this Year 2 Carryover, but it’s really… we’re in Year 2 of SOR, it’s really year one of Carryover funding for SBIRT implementation.
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Sherry Szczuka DSAMH: We’re going to cover the SBIRT model screening.
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Sherry Szczuka DSAMH: We’re going to have an open discussion with you and answer any questions you may have. We’re also going to start with a little bit of the DTRAN treatment, Delaware Treatment and Referral Network. Hopefully all of you have either registered or have received your training.
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Sherry Szczuka DSAMH: And then we’ll have next steps and wrap-up for all of you. One of the things I’d like to remind all of you, because I am on the compliance side of the DSAM team, I have to remind you that all of you have
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Sherry Szczuka DSAMH: signed letters of agreement with DSAM, and all of you are required to attend this training, or at least one person from your organization. So, we want you to have successful
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Sherry Szczuka DSAMH: projects, and part of that is to ensuring that you are trained appropriately, you have any guidance that you need with implementing SBIRT, and then if there’s any other questions that we can help you with.
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Sherry Szczuka DSAMH: Technical assistance, or embedding this process into your organization after the grant funding ends.
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Sherry Szczuka DSAMH: Next slide, please.
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Sherry Szczuka DSAMH: Alright, so very quickly, a overview with SOR implementation.
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Sherry Szczuka DSAMH: Next slide.
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Sherry Szczuka DSAMH: All right, so some of the background. DSAM, we’re part of the state opioid response.
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Sherry Szczuka DSAMH: grant, which we get from the feds. It’s a SAMHSA grant. DSAM is the recipient of the grant, and it is for us to implement evidence-based strategies to address the opioid and stimulant use epidemic that has been going on now for
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Sherry Szczuka DSAMH: at least 4 iterations of SOR, probably since around 2020.
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Sherry Szczuka DSAMH: TAP is a, specific program within the
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Sherry Szczuka DSAMH: DSAM initiative and with SOR funding, and it’s to expand the state’s capacity to engage and serve populations with OUD and STUD.
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Sherry Szczuka DSAMH: Next slide, please.
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Sherry Szczuka DSAMH: So, what are your projects going to look like? You’re going to implement
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Sherry Szczuka DSAMH: OUD and STUD screening, you’re gonna do a brief intervention, you’re gonna do a referral to treatment, and follow-up. And usually we call it SBIRT with a little plus after the T,
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Sherry Szczuka DSAMH: And that is our take on the follow-up, because the follow-up is really the outcome that we’re looking for, because SBIRT is a comprehensive, integrated approach to the delivery.
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Sherry Szczuka DSAMH: Of early intervention and referral into treatment services for persons with substance use disorder, as well as those who are at risk for developing these disorders.
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Sherry Szczuka DSAMH: Outpatient medical practices, including primary care practices, federally qualified health centers, women health practices, infectious disease practices, dental practices, physical therapy groups.
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Sherry Szczuka DSAMH: ophthalmology practices.
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Sherry Szczuka DSAMH: churches, other hospital and faith-based organizations, hospital-based systems, including emergency departments and other community settings, provide opportunities for early intervention with individuals at risk for SUD, or before
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Sherry Szczuka DSAMH: before more severe consequences occur. So, you are at the front line of that beginning of the process of helping people. Next slide, please.
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Sherry Szczuka DSAMH: So under the 4A tier, it is to implement projects for persons with OUD and STUD. It is a screening, it is a brief intervention, it is a referral to treatment, and it is follow-up available.
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Sherry Szczuka DSAMH: Projects had a maximum award of up to $75,000.
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Sherry Szczuka DSAMH: That’s a project up to $75,000 if it was for a full 12-month implementation period. All of you are on a abbreviated,
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Sherry Szczuka DSAMH: grant cycle, if you will. Most of the projects, I believe, are four and a half months. We have some mental health counseling groups, we have physical therapy groups, we have a chamber of commerce. I don’t think we have any…
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Sherry Szczuka DSAMH: I don’t think we have any, faith-based organizations this round. Usually we do, and we have other practices, like chiro… chiropractic practices. We also end up with, we have some police agencies involved with us this round.
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Sherry Szczuka DSAMH: So, I’m thrilled with the…
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Sherry Szczuka DSAMH: applicants that were selected for SBIRT, and I’m thrilled with the work that you’re going to do within your communities.
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Sherry Szczuka DSAMH: Next slide, please.
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Sherry Szczuka DSAMH: So…
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Sherry Szczuka DSAMH: a very high-level overview of the technical assistance activities that you’re going to be required to do. There was a pre-implementation survey. I believe everyone has completed that.
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Sherry Szczuka DSAMH: That is really for DSAM to gauge your knowledge and understanding of SBIRT and what will be required of you. There’s also online SBIRT modules that I believe all of you, or if not all of you, most of you have
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Sherry Szczuka DSAMH: completed. I see it says thank you on there, so I’m thinking most of you have done that.
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Sherry Szczuka DSAMH: And then there will be virtual peer learning cohort series, starting today. Today’s the first one for all of you, your subrecipients for this and the peer learning on SBIRT implementation. There’s also
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Sherry Szczuka DSAMH: a date, it looks like next week, and then another one in the beginning… the week after the first week of August. I know that’s a short time frame, but
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Sherry Szczuka DSAMH: Being the short grant cycle, we want to get you trained and up to speed.
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Sherry Szczuka DSAMH: and start implementing your project, and for you to be comfortable with it. And if you’re not comfortable with it, to ask us questions and engage with us so we can give you one-on-one technical assistance if needed. And that’s the last line, the one-on-one technical assistance. It’s available at your request.
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Sherry Szczuka DSAMH: Or we can assign it if we think you need additional assistance. It’s just part of the requirement that we have to report to SAMHSA, and we need to ensure that
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Sherry Szczuka DSAMH: organizations that we’re giving funding to is, is able to produce a good SBART project, and to have meaningful outcomes, and to make the impact on your local communities.
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Sherry Szczuka DSAMH: Next slide, please.
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Sherry Szczuka DSAMH: So the other item that’s going to happen is you’re going to have SBIRT fidelity monitoring assessments. You’re going to have at least one of them in August with one of the program integrity specialists. We’ll do an on-site visit with you, and it will be a role-playing exercise.
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Sherry Szczuka DSAMH: For you to, engage with the program integrity specialist of a, you know.
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Sherry Szczuka DSAMH: Being the practitioner, the clinician, and the program integrity specialist being the client, and how you would
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Sherry Szczuka DSAMH: Gauge and answer your questions to the client, and then, like a real life
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Sherry Szczuka DSAMH: Training session, at your location where you’re comfortable.
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Sherry Szczuka DSAMH: And then feedback will be supplied to you, just to give you a general
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Sherry Szczuka DSAMH: Feedback of what we can do better next time, process improvement.
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Sherry Szczuka DSAMH: So we don’t expect all of you to be,
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Sherry Szczuka DSAMH: experts with SBIRT, but we expect you to, as we get through the grant term, to learn and do better, and have a really good understanding of it by the time we get to the end of September, so that you’re able to implement
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Sherry Szczuka DSAMH: Export seamlessly into your organization.
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Sherry Szczuka DSAMH: There will also be a required share-out meeting at the end of the grant term in September. It will be a very high-level presentation that you’ll need to engage with us.
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Sherry Szczuka DSAMH: Usually we ask for, you know, what outcomes you have, how well you did, maybe some challenges that you had, because it’s also a learning opportunity for DSAM
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Sherry Szczuka DSAMH: of future awards that are happening with SBIRP.
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Sherry Szczuka DSAMH: So with that, next slide, and I believe this is where I turn it over to Amy Shanahan.
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Amy Shanahan: Yeah, unless folks have questions for Sherry and the team on what was covered so far.
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Amy Shanahan: I see Amy shaking, there had no any… anyone else, and feel free to write it in the chat, like Sherry said.
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Amy Shanahan: Hi, everyone. I am Amy Shanahan. I’m hanging out here in Pittsburgh. We’re getting some of the… some of the weather heading… heading, I think, your way, but we’re getting a little bit of thunderstorms, but fingers crossed, I got 45 good minutes or so with
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Amy Shanahan: the internet that I’ll be with you. So, I’m not gonna dive too much into who I am, other than to say my career has been spent in addiction medicine care, and I’m very passionate about this topic, and I want this to be for you, especially with this fast track.
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Amy Shanahan: You had to, commit to the online stuff, so…
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Amy Shanahan: We’re going to take each layer of the… of the SBIRT model in each meeting to kind of dive in, and I invite you to think about it if you haven’t already started to think about, hmm…
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Amy Shanahan: how is this going to look? Because when Sherry said by September, maybe not experts, but have a nice, streamlined,
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Amy Shanahan: implementation process, which always can be easier said than done sometimes, because there’s things that we have to think about when we implement SBIRT. Sounds easy.
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Amy Shanahan: Until you start to think about the workflow, and who’s going to be doing things, and… and what we share. And I know… and I love to tell stories. I hope you will too, and ask questions, about where you are.
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Amy Shanahan: So, I shared a little bit about my background, that I’ve been in addiction medicine care on the treatment side of things, so if you referred folks, I’d usually be the recipient of the folks that you’re serving in the process model of SBIRT.
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Amy Shanahan: But right now, I don’t work for any entity other than my own.
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Amy Shanahan: I’m a consultant, and I am also a consultant with ORN.
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Amy Shanahan: And I’ve been working with DSAM. I can’t even count how many years, Sherry, maybe 3? Could be more.
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Amy Shanahan: I’m thinking of taking up residency in Delaware, but, you know, we’ll see. But ORN is an organization, Opioid Response Network, that is funded by SAMHSA.
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Amy Shanahan: So I’m just gonna go through these slides, to let you know that we are here for you, even outside of this support that you’re getting from DSAM,
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Amy Shanahan: There’s other things that we provide around technical assistance and support for evidence-based prevention, treatment, and recovery in opioid use and stimulant use disorders.
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Amy Shanahan: So, we accept pretty much a lot of requests. If it has anything related to substance use, just mention some opioid and stimulants as part of the equation, and oftentimes requests are accepted. Education, training.
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Amy Shanahan: technical assistance, implementation work. I wish I had this in my career, because I always wanted to do things, and it just took a lot of… a lot of resources and support, so…
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Amy Shanahan: If you did reach out to the ORN, you would, be contacted by your local, what we call, tech transfer specialists.
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Amy Shanahan: Who will then identify what content matter expert, or what resources are needed based on your request.
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Amy Shanahan: So just to get into a little bit of the weeds, but the simple thing is, you can just click on the link, it’s a quick and easy submit your question or help.
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Amy Shanahan: Or you can actually email them directly. I think it’s a streamlined approach that they have now with just clicking on their submit a request on the top of their webpage.
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Amy Shanahan: I have to note, just like Sherry did, that this, that we’re funded by SAMHSA. I won’t bore you with the details. They’re in your slides if you want to read this whole thing. I’m going to go through that so we can get into the fun stuff of SBIRT.
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Amy Shanahan: here’s the mission of the ORN, really to build on existing efforts, and having worked with Addiction Technology Transfer Centers over the last 25 years, this was always the missing link.
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Amy Shanahan: How do we do it now? You taught me what SBIRT is, but now what? So this is where the now what is with technical assistance.
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Amy Shanahan: Here’s the mission. I jumped… jumped the slide.
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Amy Shanahan: And the beauty of the mission is not just providing support for treatment, it’s also to enhance prevention, and to help the whole continuum of care from start to recovery in communities. A big, a big,
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Amy Shanahan: a big, attention to recovery in community from the Opioid Response Network’s vision and mission.
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Amy Shanahan: All right, I think that gets us to screening, and that’s what we’re going to focus on today, so…
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Amy Shanahan: what I’m gonna provide is probably a lot of review for you all, and I think some of it’s important.
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Amy Shanahan: I’m just wondering how many of you, so I’m gonna invite you to get involved now.
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Amy Shanahan: in…
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Amy Shanahan: Let me know a little bit, you know, what… what type of folks are you serving, and what type of, care?
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Amy Shanahan: And… Are you doing Universal?
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Amy Shanahan: Screening, or targeted screening, or both.
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Amy Shanahan: So, the review starts here?
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Amy Shanahan: Univers… yeah, all right. I… I don’t have your name, but I see some back and Neck Pain Center.
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Amy Shanahan: Hello, thanks for raising your hand.
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Advanced Back & Neck Pain Center: Hey there, this is, Dr. Travis McKay from Advanced Back and Neck Pain Center. We are doing universal screening to all of our patients using the DST10 form.
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Amy Shanahan: Great.
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Advanced Back & Neck Pain Center: Now, I do have a question about our screening. It seems, you know, when we are having positive screenings, nearly all of them are ones. How do you do a screening for a score of 1? So the lowest possible risk on there. What sort of steps would you take to, you know, you don’t want to…
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Advanced Back & Neck Pain Center: I guess seem overly pushy or cautious for the patient, so how would you approach that?
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Amy Shanahan: That’s a beautiful question. Happy to hear that that’s your number. Usually we just, you know, affirm them. Excellent. If… if it’s part of your…
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Amy Shanahan: If you have access to the resources, sometimes, depending on what they answered, give them references and resources, and yeah, you don’t want to inundate them. I think just, like.
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Amy Shanahan: And I don’t know if you do this in back and neck pain care, just like when I walk into my doctor’s office, which I did recently, and I don’t even question it, and I should, and I want to. They ask me to step on the scale, which I hate, and they take my blood pressure.
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Amy Shanahan: they don’t even have to talk to me about it anymore. And to me, that’s the dream of this universal screening, Doctor, and I missed your name, so I’ll just call you doctor for now, if that’s okay.
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Amy Shanahan: So, just… Affirming them.
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Amy Shanahan: And then… then you’re good. I think what… what I would consider, too, is how often, then, do you do universal screening? If… how frequently do you see patients? If you see them again in a year.
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Amy Shanahan: Are you gonna screen them again?
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Advanced Back & Neck Pain Center: I think that for us, usually, probably the minimum amount of time between screenings would be 4 weeks, but the maximum would be about 3 to 6 months.
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Advanced Back & Neck Pain Center: Depending on how often we’re seeing this patient, or what level of pain they’re in.
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Amy Shanahan: Yeah, and you know, especially around pain, I just know from being on… so my background in a lot of my care in Pittsburgh was at UPMC, and we had pain management clinics, and we’d have to meet with each other.
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Amy Shanahan: Because the folks that were going to the pain centers didn’t want to tell
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Amy Shanahan: the whole truth and nothing but the whole truth sometimes. So sometimes when folks are building rapport with their provider, they might feel, if they’re not judged, which is an important aspect of screening and brief intervention, helping them feel comfortable and safe to say.
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Amy Shanahan: Well…
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Amy Shanahan: I have run out of my opiate medication sooner than I needed… sooner than I should have, right? So…
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Amy Shanahan: I think that that’s how you get to…
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Amy Shanahan: How do you get to know your patient population if they’re truly not
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Amy Shanahan: Taking more than prescribed, or getting to the point where they’re physically dependent on the opiate, which is a little bit different than having an addiction.
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Advanced Back & Neck Pain Center: Yeah.
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Amy Shanahan: So these are conversations that we’ve had in pain management and in addiction, care that some people don’t want to…
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Amy Shanahan: admit it, and I think a point that I’d like to make, too, is
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Amy Shanahan: How you ask that universal screening might be important as well.
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Advanced Back & Neck Pain Center: Sure. We’re kind of in a unique perspective because, you know, we’re, I guess, an alternative pain management office, so we do chiropractic, we do PT, we do massage, so I think a lot of the patients that are coming to us
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Advanced Back & Neck Pain Center: you know, they at least have the intention of treating pain without any medication, not to say that they’re not, you know, co-treating with somebody else or, you know, using things on their own, but
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Advanced Back & Neck Pain Center: That makes it ideally a little bit easier to connect with them. We don’t gotta worry about them worrying about their prescription if we have these conversations or anything like that.
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Amy Shanahan: Yeah.
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Amy Shanahan: Excellent, and you know, so it’s a comprehensive, program that you’re offering, and I think to not assume
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Amy Shanahan: that people are… and I… to not assume people are lying or misrepresenting the truth, there’s a reason why they have done that over the years, because of stigma, as you know. But being able to approach folks with an assumption that
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Amy Shanahan: hey, sometimes people take an extra piece of medication, and they might be, good patients and want to follow the doctor’s orders, and they’re a little shy to say, yeah, I took an extra
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Amy Shanahan: an extra opiate. So, again, it’s all in the how you asked the question, and I’m going to share one of my personal stories.
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Amy Shanahan: Someone did a screening on me in my recent doctor visit, and they kind of spoon-fed me. And I was like, I’m just gonna say yes.
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Amy Shanahan: Like, for example…
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Amy Shanahan: So, you know, how often do you use alcohol? Like, once? Twice a month? Every other month?
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Amy Shanahan: And they were giving me the answers.
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Amy Shanahan: I’d be careful about that.
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Amy Shanahan: Because I wanted to just answer yes and get through it.
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Amy Shanahan: So, just a word of caution.
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Amy Shanahan: What do you think about that, folks?
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Advanced Back & Neck Pain Center: Definitely, thank you.
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Amy Shanahan: Yeah.
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Amy Shanahan: So universal… a beautiful universal screening is very open-ended.
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Amy Shanahan: What substances or alcohol have you used in the last year.
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Amy Shanahan: Or, however you want to narrow it down.
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Amy Shanahan: But the tricky thing about that, too, for pain management is
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Amy Shanahan: Asking the question in a way, how often have you taken your medication?
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Amy Shanahan: as prescribed or not as prescribed, because there’s a whole different story there than just… people will say, I don’t use drugs or alcohol.
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Amy Shanahan: And so you might want to ask them about their… their use of taking their medication as prescribed.
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Amy Shanahan: Right.
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Amy Shanahan: So targeted is, what I’ve seen happen more routinely than universal, so I love to hear when people are universally asking.
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Amy Shanahan: My physician did ask me depression scale questions, and asked permission if she could ask them, which I thought was a nice touch.
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Amy Shanahan: And asked me a few questions.
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Amy Shanahan: Just as they are written, and she doesn’t know that, but I’m familiar with the depression screening scales.
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Amy Shanahan: So, I was ready for them, and answered them quickly. But, you know, docs are quick. If the doctor’s doing the screening, they’re quick to be done with it. So it depends on, also, something to think about is who’s doing the screening? In what part of the process in your care?
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Amy Shanahan: Targeted is one of the common ones that I see a lot when people are implementing SBIRT, where they provide it to a specific group of people, especially if you’re talking about an ERED, when people come in with a positive blood alcohol, or come in under the influence of substances, or are in some level of withdrawal.
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Amy Shanahan: So this eliminates the bigger picture, which I’ll get to in a second, that we’re missing out on some folks. My passion about the universal screening is that if you did that routinely, like you did the weight and the blood pressure.
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Amy Shanahan: eventually I might say, yeah, I ran out of my medication, or I’ve been drinking a little bit more since the death of my spouse, or something that I feel comfortable because it’s a routine question, instead of this
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Amy Shanahan: And that’s…
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Amy Shanahan: how the person asked me, when they were asking me about my alcohol use, they seemed more uncomfortable with it than I would. Gotta ask you these… you… you only drink, like, a couple.
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Reginald Parker: Inc.
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Amy Shanahan: And… and answered… answered… kind of gave… fed me the answers.
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Amy Shanahan: So I’m… I’m mindful of that, and appreciative of… of people feeling uncomfortable, and at the same time, knowing that when you,
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Amy Shanahan: When you do universal or pre-screening, that you…
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Amy Shanahan: Ask the question in an open-ended way.
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Amy Shanahan: So what are your thoughts so far?
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Amy Shanahan: See some chats coming in.
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Amy Shanahan: Or ideas.
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Amy Shanahan: All right.
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Amy Shanahan: So, why screen… you can all see the slides still? My screen was jumping around a little bit.
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Amy Shanahan: Still good?
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Victoria Pauline, (she/her) | BBS: Yeah, we’re good, Amy.
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Amy Shanahan: Okay, cool. Thanks.
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Amy Shanahan: So, you all probably know this, but the last… I’m bringing your eyes to the last…
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Amy Shanahan: Part of here, 90% people go undetected or untreated.
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Amy Shanahan: Because, because they’re not screened routinely. So we know why to detect… to detect early. I often have said that I would be happy if you put addiction medicine providers, special… specialists out of business.
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Amy Shanahan: That means that we’re catching people’s…
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Amy Shanahan: concerns earlier. And I think about that with any chronic conditions, that if someone had a risk of diabetes, or risk of hypertension, or heart disease.
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Amy Shanahan: We’d want to screen early, that’s why we have early screening, and it’s the same thing. And you may all know this and have been experiencing this, but alcohol and substance
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Amy Shanahan: use, oftentimes is the primary cause of some other health conditions or other injuries or issues, and maybe you experience that with back pain and PT stuff and other areas of folks, whatever you focus on.
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Amy Shanahan: here that sometimes you could really think about, oh, I broke my leg because I was intoxicated, or under the influence, or I got in that accident, or I was injured because of
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Amy Shanahan: Not always, but it’s something to keep in mind that
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Amy Shanahan: I think, like Sherry said, you’re at the front lines of this.
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Amy Shanahan: So, NIAAA, this is all around alcohol,
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Amy Shanahan: And this often, maybe when people start to think about their own use, start to go, hmm…
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Amy Shanahan: Where do I fit?
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Amy Shanahan: So, they have defined low to harmful use and hazardous use, so these terminology comes up. Hazardous, a person’s at risk for… for adverse consequences. You know, and what I say about that from my background in addiction medicine is…
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Amy Shanahan: Being mindful that just because someone might be using
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Amy Shanahan: in this way, that they’re at risk for adverse consequences doesn’t always mean that they have a full-blown problem or a full-blown diagnostic addiction problem. So we have to be mindful of that. I’ve seen, at least in my work, that people get referred
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Amy Shanahan: And maybe because the medical provider may feel uncomfortable or not competent to, or have the time or resources to, intervene early, so we’ll refer them out, for a specialty assessment. And there’s time and place for that.
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Amy Shanahan: You already mentioned DAS, but here are some examples of the screening,
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Amy Shanahan: Screening tools… alright, there we are. It is bouncing around. I got two different screens up, that’s really confusing me, right?
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Amy Shanahan: And I want to just see your faces. I’m trying to see your faces and my screen. So there’s several screening tools for adults.
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Amy Shanahan: One for adolescent, and then the five P’s for pregnancy. You may already have been exposed to these. I’m going to stop sharing, because I want to show you one other thing, that’s online and not on my screen, on my slides.
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Amy Shanahan: I’m wondering if folks are familiar with TAPs.
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Amy Shanahan: How many of you are familiar with TAP supply?
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Amy Shanahan: Get that pulled up for you to see, visually.
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Amy Shanahan: Any folks familiar with TAPs?
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Amy Shanahan: Look, I can see your faces, so even if you nod, or…
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Amy Shanahan: No, I see a couple… no. Not sure what to… not the song taps in the military, if folks… But I’ll show you the taps, just so… because it’s an online tool.
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Amy Shanahan: That might be helpful for some.
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Amy Shanahan: And it looks like this, and it covers everything. Can folks see that? If I could have a verbal yes or no, because I now can’t see your…
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Amy Shanahan: Faces?
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Amy Shanahan: Can you see this?
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Amy Shanahan: Beautiful. So, TAP stands for Tobacco, Alcohol Prescription Medication, and Other Substance Use. So, you can see here that
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Amy Shanahan: You can select as the clinician, or you can
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Amy Shanahan: Fill it out as a patient client, so feel free to check that out and play around with it for yourself as well. You could learn more about the tool.
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Amy Shanahan: But I’ll… I’ll pretend I’m the patient and get started, and it tells you what the health survey asks me questions about.
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Amy Shanahan: I won’t go through it in great detail, but just show you. So see, this is the… this is the universal question. In the past 12 months, how often have you used
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Amy Shanahan: any of these things. And my doctor asked me this question, the doctor’s office asked me if I, used any tobacco products in this way, vaping, etc, and then got into the next question about
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Amy Shanahan: How often have you had? Now, this is where it went south, because the person actually fed me the answer, in a sense of.
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Amy Shanahan: Well, you probably have, like, one or two, like, I said yes, I… I have out… I use alcohol sometimes. Oh, you probably just have it. So, this is a better way to ask it. So, it’s gonna then get… I’m just gonna keep saying never to not reveal myself, and…
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Amy Shanahan: And then it asks about using prescription medications, and here’s the question, feeling… just for the feeling and more than prescribed, or that were not prescribed for you. So it gives you the verbiage there.
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Amy Shanahan: And so on. So TAPS is an online… some folks just tap into this, ha, pun intended, and use it, because it’s right there, and it’s easy access, and if they have the wherewithal to have it on their, iPads, if you have an iPad.
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Amy Shanahan: Or, a way for folks to fill that out in your waiting room.
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Amy Shanahan: thoughts, questions about the different screening tools? Have you been thinking about what tool you’re gonna use?
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Amy Shanahan: Or I’ve already started trying to use before I show my screen again.
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Amy Shanahan: What are you already thinking about?
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Teach21 Enrichment Inc. – Latoya Pendergrass: Well, now that you showed us TAP, and it has the online tool, now I’m reconsidering if we’re gonna use TAP or not, yeah.
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Amy Shanahan: Great. It encompasses everything.
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Teach21 Enrichment Inc. – Latoya Pendergrass: Yes.
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Amy Shanahan: Instead of having to do the audit, and then maybe the DAST.
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Amy Shanahan: Or, you know, and you… obviously, you could have the craft in your back pocket, or the five P’s if you… if you’re, treating adolescents and pregnant women. You want to have those at your fingertips as well, because there’s different ways of asking questions for that. Kristy, did you have something you wanted to share?
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Kristy Gibbs/Unique Minds: You said Kristy, you talking.
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Amy Shanahan: Yeah, yeah, I saw you unmuted, so I thought maybe.
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Kristy Gibbs/Unique Minds: No, I was responding to, Lisa. She had asked me.
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Amy Shanahan: Okay.
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Kristy Gibbs/Unique Minds: My apologies.
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Amy Shanahan: No worries, no worries, just wanted to check. Yeah, so thanks for the DAS, very effective, easy to use.
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Amy Shanahan: Screening tool as well.
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Mbwidiffu Dibal – Menopause Clinic: I was gonna ask, like, if we decide to use the TAPs, is it… how do we get the data?
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Mbwidiffu Dibal – Menopause Clinic: Maybe we need to create a login to it, or something?
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Amy Shanahan: Oh, that’s a good question about collective data with the TAPs.
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Amy Shanahan: I think you do have access to it as a provider. I’m gonna go backwards while I’m on this to…
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Amy Shanahan: See? That’s one thing I didn’t even…
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Amy Shanahan: Because I know if I go in, I could see my results.
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Amy Shanahan: I’m gonna just do this as a provider.
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Amy Shanahan: And it’s part of NIH, so you probably could…
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Amy Shanahan: Yeah, get some support from them about the data.
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Teach21 Enrichment Inc. – Latoya Pendergrass: And you can print and share your results.
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Amy Shanahan: Yeah, I see that,
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Amy Shanahan: Alright, good question.
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Teach21 Enrichment Inc. – Latoya Pendergrass: Really good.
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Amy Shanahan: And quick.
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Teach21 Enrichment Inc. – Latoya Pendergrass: Yeah, quick, it’s all right there. It’s really good.
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Amy Shanahan: And whether you use the TAP
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Amy Shanahan: or the DAST, or the audit.
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Amy Shanahan: Using that structure is so important, because they give you the language, and then they give you the results.
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Amy Shanahan: You don’t… I mean, obviously you want to use terminology that you’re…
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Amy Shanahan: Population of people that you serve understand?
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Amy Shanahan: But it gives you the phrasing.
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Amy Shanahan: In a way that… I mean, I knew when the medical assistant was asking me about my alcohol use, she didn’t seem uncomfortable. I’ve had that. I’ve had people feel really uncomfortable, like they were very nervous. She seemed a little more confident than I’ve had in the past.
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Amy Shanahan: But the fact that she was feeding me the answers was… was pretty risky.
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Amy Shanahan: Cause I’m just… I’m just gonna say yes or no.
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Amy Shanahan: And, you know, you want to hopefully make it a little bit more open, especially if you’re having your medical assistant ask the question.
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Amy Shanahan: So that they get, and maybe role play with them, so that they,
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Amy Shanahan: So that you could witness it, and hear it, and help them feel more comfortable. Because it’s usually around competence, because it’s a new thing if they’re not used to it.
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Amy Shanahan: I know that my mother-in-law was asked some sexual orientation and gender identity questions, and she felt so anxious because the core medical assistant was more nervous than her.
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Amy Shanahan: about it, so that’s one thing in the implementation process, is helping whomever is in that process to feel comfortable, practicing. Because you know how it is, you practice asking these questions on a screening tool, and you’re almost reading it word for word.
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Amy Shanahan: And it takes them a while to get comfortable and some practice.
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Amy Shanahan: So whatever tool you’re using, use the flow, use the process, and…
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Amy Shanahan: Yeah, go ahead.
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Mbwidiffu Dibal – Menopause Clinic: since we’re supposed to make this an interaction, I would say that one of the things that we’re running into… so my population is, menopausal women, so women in their, you know, late 40s into and up, and
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Mbwidiffu Dibal – Menopause Clinic: a lot of times, what I run into is… so I use the universal screening, and it’s the DAST 10, and
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Mbwidiffu Dibal – Menopause Clinic: You know, they answered the first question, have you ever used drugs, other than…
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Mbwidiffu Dibal – Menopause Clinic: than those required for medical reasons, and the answer is no. But then they still have to answer all of these questions. Do you abuse drugs? Are you unable to stop? So I get, like, a little bit of a pushback. Oh, I don’t do drugs, why do I have to answer the rest of the questions? How,
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Mbwidiffu Dibal – Menopause Clinic: should we handle that? We still tell them they still need to do it, but I want to have, like, a good or a better answer over saying you’re required to do it.
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Amy Shanahan: Yeah… well, for me, I wouldn’t ask the question. If they said, no, they don’t, I wouldn’t ask the follow-up questions.
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Amy Shanahan: The modified NIDA Assist, which is not on our list.
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Amy Shanahan: I’ll write that in the chat.
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Amy Shanahan: Modified… NIDA Assist?
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Amy Shanahan: screening tool.
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Amy Shanahan: Starts Universal?
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Amy Shanahan: What of these things have you used in these past months? And that’s a great question.
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Amy Shanahan: And then the further screening then only targets whatever they said yes to.
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Amy Shanahan: If you said yes to tobacco, then we’d say, how much in the last 12 months? If you said yes to opiates, then we would dive into the rest, and we wouldn’t
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Amy Shanahan: We wouldn’t… I mean, it… why would I continue to say how much alcohol you use if you said you don’t use any?
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Amy Shanahan: So that… that would take up your time and disengage the worker with the patient. As you, like you said, you get pushed back, like, why are you… I just told you I don’t use that. Why are you doing this?
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Mbwidiffu Dibal – Menopause Clinic: True.
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Amy Shanahan: Great question, but the modified NIDA Assist, I like that one, because it does the universal screening.
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Mbwidiffu Dibal – Menopause Clinic: Thank you.
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Amy Shanahan: Yep, and then only dives into the substance that they say yes.
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Amy Shanahan: And even then, it narrows it down. Have you used any of these in the past 12 months? Because I’d tell you, I used tobacco when I was younger, but don’t keep asking me, because I don’t use any more tobacco, and get on with maybe the other substances.
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Amy Shanahan: And if you looked at that,
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Amy Shanahan: you could see the projection of how they drill it down. I’ve seen it done wonderfully, uploaded on an iPad, and then once you just ask whatever substance… answer yes to substances, it then only asks you those follow-up substances.
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Amy Shanahan: Yeah.
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Kevin Wilcox-DWD: I have a question.
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Amy Shanahan: Yep.
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Kevin Wilcox-DWD: So, we use the Universal, DAS 10.
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Kevin Wilcox-DWD: And… number 3.
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Kevin Wilcox-DWD: It’s where… Everybody that I have do surveys, they’re saying, like, the wording.
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Kevin Wilcox-DWD: is… is mixed up.
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Kevin Wilcox-DWD: It’s like, trying to think of the exact wording of it, it’s… I don’t have a problem with…
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Kevin Wilcox-DWD: Stopping, or… or something like that?
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Mbwidiffu Dibal – Menopause Clinic: I can read, I can read the question for everyone. Please, thank you. Yeah, because I get the same pushback. I’m glad you asked that. Are you unable to stop abusing drugs when you want to?
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Mbwidiffu Dibal – Menopause Clinic: Yeah, so my… for my patients, it’s more like, well, I don’t use in the beginning, so how do I even answer that question? So that question is supposed… the answer is supposed to be a yes,
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Mbwidiffu Dibal – Menopause Clinic: But they don’t use drugs anymore, so if they say no, then that gives them a one point when they’re not supposed to have a point at all.
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Amy Shanahan: Yeah. And, you know, these are good questions to ask. Is the screening tool you’re using the most appropriate for the people that you’re serving? And, you know, when you read that out loud, and I have it in front of me as well.
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Amy Shanahan: I… I have some disc… I have some discomfort. My… my cat is joining us. I… I… I can’t even see her. Oh, she’s… she’s resting.
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Amy Shanahan: Usually she’s camouflaged back there. I don’t see a squirrel, I see a cat when I’m reminded. What I don’t… I love that you picked that up, Kevin. I don’t like, are you unable to stop abusing
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Amy Shanahan: drugs, that’s one word that is stigmatizing. How about, are you unable to stop using when you start? And that’s a common thing for some folks who
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Amy Shanahan: who use, and if they have an addiction, it’s a common thing with alcohol, that, man, when you start out, you intended to only drink 2 drinks, but something clicked and you just kept drinking, and that’s what that question gets at.
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Amy Shanahan: So, I wonder, how would you ask that question to get at the answer?
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Amy Shanahan: Because I think the important thing is the question is helpful, How would you ask it?
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Amy Shanahan: You know, I’m wondering, when you do use…
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Amy Shanahan: Do you have moments when it’s hard to stop and you keep using more than you planned on?
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Amy Shanahan: What do you think of that one? That’s just my idea that came off my head.
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Amy Shanahan: That’s what I think it’s getting at.
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Amy Shanahan: But great eye for that, because it’s… it’s stigmatizing language, number one.
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Amy Shanahan: Because not everybody is abusing, they’re just using.
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Amy Shanahan: I know. Sounds funky, doesn’t it?
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Amy Shanahan: I hope that’s helpful.
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Kevin Wilcox-DWD: Yes, it was.
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Amy Shanahan: So that’s one thing I say, that use the structure of the screening tools, and if you find something wonky like that, and it doesn’t feel right, doesn’t land well with the folks that you’re talking with.
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Amy Shanahan: try to find it in a way that you can get at the answer without being offensive or stigmatizing, and I don’t know… I know you don’t intend on doing that, but your folks will just, oh, I gotta read this question and just do it, because that’s what I’m instructed to do.
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Amy Shanahan: And that makes sense. And then that’s when you get a medical assistant that asks it in an uncomfortable way, because they feel uncomfortable with it.
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Amy Shanahan: And thank… thankfully, yeah.
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Mbwidiffu Dibal – Menopause Clinic: I’m gonna ask one more question, and I’m gonna not ask anymore. This is for you. Because I’m asking a lot. Is it, what have you, found, when it comes to the screening, whether…
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Mbwidiffu Dibal – Menopause Clinic: asking, like, reading it off for the patients, or giving them the tool on a piece of paper and having them answer themselves. What method would you say is preferred or more effective?
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Amy Shanahan: I think you should keep asking questions, because you have great questions. Yeah, that’s an… that’s a good… that’s an… I think it… it depends. It depends on the screener, it depends on their comfort level with… with it.
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Amy Shanahan: If… if you feel uncomfortable, if you’re feeling judgmental about it, you know, if you’re seeing someone who’s pregnant, and you’re screening them, and you have a judgment about they shouldn’t be using if they’re pregnant, they’re gonna read it on your face.
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Amy Shanahan: Yeah, got some nodding heads there.
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Amy Shanahan: The flip side to that is, I know I’m thinking I’m putting myself in the session, and I’m clicking, clicking, clicking, clicking, clicking in the waiting room, and I’m just answering it to get it done, because I want to get in… get in and get out of the doctor’s office. So… so there’s… there’s something to be said for having rapport.
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Amy Shanahan: So I guess if I had to answer that question and you wouldn’t let me go without answering it, I would say have good rapport and do it, as part, because sometimes having the kind, compassionate, empathic conversation is an intervention in and of itself.
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Amy Shanahan: So that’s… that’s my…
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amy rust- Attack Addiction: I find that sometimes my client… the people in the public that I’m working with, might not understand what it is that we’re asking.
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amy rust- Attack Addiction: So, some of them, I’ve had to really break down the questions of, you know, I’m not talking 20 years ago, I’m talking about, like, right here, right now, you know,
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amy rust- Attack Addiction: I understand that you’ve, you know, been clean before and you’ve relapsed, but, like, where we mean right now. And some of them just don’t understand, like, I’ve had to really, describe some of the questions before, so I don’t think, like, personally, I wouldn’t hand them, but,
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amy rust- Attack Addiction: I guess you’re right, with certain people, they might be judgmental, or not…
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Amy Shanahan: Yep.
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Amy Shanahan: No, that… thanks for adding that, Amy. Good points you have there. Again, it’s… it’s knowing who’s doing the screening.
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Amy Shanahan: you know, being able to have a conversation in a non-judgmental way, because, you know, I’ve… I know that
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Amy Shanahan: You know, my doctor was doing the depression screening because she probably had to.
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Amy Shanahan: And I could hear it.
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Amy Shanahan: I can hear it in her check, check, check. Is it a checklist, or is it a conversation with rapport and engagement? And to me, the latter is the ideal. That’s what we’re hoping for. Hope on deck, I love that. That’s what we’re hoping for, that we start to change the way we talk to people
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Amy Shanahan: And about their substance, alcohol, and tobacco use in order to have a healthier community.
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Amy Shanahan: I have a few more slides to get through, you probably already know this stuff.
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Amy Shanahan: But yes, keep those questions coming, because they’re better than me just talking at you about this data that you’re probably somewhat familiar with. Because now we’re just getting into, you know these things around the results of the… and being able to understand
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Amy Shanahan: The range, so we’re just having examples that the audit
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Amy Shanahan: has a range that’s different than the DAST,
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Amy Shanahan: Eventually, as you get this as part of your standard,
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Amy Shanahan: You’ll get a sense of this off the top of your head.
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Amy Shanahan: Again, zero abstainers. I wouldn’t be doing much of anything. My kind… kindness around asking the question is an intervention in itself.
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Amy Shanahan: Because maybe if the person didn’t feel safe to answer the questions truthfully, we’re getting a negative score, but it might have been, truthfully, a positive score, and because I asked it in a kind, caring, non-judgmental way, maybe next time I ask,
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Amy Shanahan: They might feel safer and more comfortable.
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Amy Shanahan: Some risk zones here, you have the 1, 2, 3, 4 in the audit, risk zones.
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Amy Shanahan: Again, low risk is really, you know, like we started off, excellent, good for you. Feel free to, update us if something changes. You know, just like a normal thing. Are you concerned about something? Feel free and comfortable to bring it in.
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Amy Shanahan: And, you know, Zone 4 is the referral to treatment. Sometimes in Zone 3, you might have that. They may have experienced some negative effects, but they may not need specialty care yet. And I think that that’s what I’ve seen, once we get past
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Amy Shanahan: Zone 2, people are wanting to refer people to detox. Well…
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Amy Shanahan: I don’t know that… I don’t know that I need to go to,
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Amy Shanahan: kidney dialysis, just because I said my side aches, right? I’m exaggerating a little bit here, but I don’t need to go to specialty care if I’m just at risk. So, some things to consider. And you’ll see that DAST is,
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Amy Shanahan: Similar here.
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Amy Shanahan: In the range of maybe using different words, So…
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Amy Shanahan: But again, I think to your beautiful questions and, you know, Kevin, you’re noticing the language.
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Amy Shanahan: let the people know what these things mean, and I’m gonna, steal from the book of one of my beautiful mentors and say, you know.
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Amy Shanahan: Based on your score, Zone 2 on this screening tool.
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Amy Shanahan: Indicates that you have… you’ve got some riskiness going on, which might mean if you continue this way.
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Amy Shanahan: There might be some impact from your use.
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Amy Shanahan: It’s not a threat. It’s not a warning. There may be some risk to your health.
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Amy Shanahan: There may be some risk to… hmm. So, there may be some risk.
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Amy Shanahan: Zone 3 conversation, is all about harmful, so that’s a… that can be a judgmental word. Zone 3, if I said, hey, you know, you scored a 5 on this desk.
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Amy Shanahan: And that tells me, based on what you’re sharing, that you’ve already had some impact.
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Amy Shanahan: some problems, and… and points them out if they’ve shared them with you. So…
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Amy Shanahan: Figuring out a way to educate the person around what the scoring means also points to what you were talking about, Amy, that having a conversation with folks around their score is so important about what does that mean? What does this number mean? What does this word mean?
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Amy Shanahan: Another note, Sherry mentioned this already, about fidelity monitoring, specific to screening. The screening monitoring will be, are you accurately assessing this for the quantity, frequency, and duration of their use?
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Amy Shanahan: The monitoring will also be around how do you navigate that level of risk, and also having a conversation around the consequences around that. So it’s not just as simple as reading the words on the screening tool, it’s being able to find it in your own language and in your own words.
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Amy Shanahan: So… just,
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Amy Shanahan: I’ll wrap up for the screening part. Universal is everybody gets some kind of screening, even if it’s a one-time, have you ever used any of these substances in the last year, to a targeted one, a targeted screening based on risk, or maybe someone’s presenting.
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Amy Shanahan: Yeah, so I’m gonna slow that down, see if there’s any other thoughts or comments before I hand it over to DSAM for the last few minutes.
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Teach21 Enrichment Inc. – Latoya Pendergrass: I just have one question, because you’re so good with your examples. You can tell you’ve been doing this for a long time. So you’re doing a screening, and you know the person is lying.
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Teach21 Enrichment Inc. – Latoya Pendergrass: What’s the conversation? Like, how do you approach it?
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Amy Shanahan: Oh… My mentor…
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Amy Shanahan: No, he’s not my mentor, I wish he were. Bill Miller, the author of Motivational Interviewing, would say.
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Amy Shanahan: That’s your secret.
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Amy Shanahan: Because if you judge them as lying, they’re protecting themselves for some reason.
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Teach21 Enrichment Inc. – Latoya Pendergrass: Okay.
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Amy Shanahan: And that’s me? I’m just speaking for Amy Shanahan, not for Opioid Response Network.
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Teach21 Enrichment Inc. – Latoya Pendergrass: If they frequent our community hub frequently, say they have kids that participate in our program, so I see you again, how long should I wait before I screen you again? Because I know that you weren’t being honest.
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Amy Shanahan: Mmm.
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Amy Shanahan: Yeah. Well, especially if they have kids involved, you know,
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Amy Shanahan: Caregivers might fear, that they might lose their kids if they answer that. So, and that’s just one beautiful example. Many people protect their
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Amy Shanahan: they’re used for different reasons, too. So, yeah, it’s your secret. Still non-judgmental, still questioning, still screening in your routine, and, you know, we can’t…
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Amy Shanahan: unfortunately save everybody from maybe every adverse thing, you know? But if the more you… you create a standardized culture where it’s…
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Amy Shanahan: you know, typical, and you’re not asking it in a fearful way. At some point. Maybe people will feel safe.
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Teach21 Enrichment Inc. – Latoya Pendergrass: Yeah, okay.
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Teach21 Enrichment Inc. – Latoya Pendergrass: What was that book again?
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Amy Shanahan: Oh, I was speaking about Bill Miller, who is the co-author of Motivational Interviewing, which is really where SBIRT kind of derives from the brief intervention stuff, and we’ll talk about that. But I’m a practitioner of motivational interviewing, which is
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Amy Shanahan: Changed my life.
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Amy Shanahan: And it’s about that. I’m not here to catch people doing something wrong.
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Teach21 Enrichment Inc. – Latoya Pendergrass: Thank you.
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Amy Shanahan: Yeah, thank you for your kind questions.
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Amy Shanahan: Yeah, Don.
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Dawn Sheehan Hope on Deck: So, we have a, a resource center, and so we see a lot of, people come in weekly, and…
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Dawn Sheehan Hope on Deck: I know that we can’t count individuals as taking it, you know, that we just count them the one time in our numbers, but…
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Dawn Sheehan Hope on Deck: some of them, I feel like I… I do this with them every single week, but not necessarily go, you know… I don’t necessarily go on to the…
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Dawn Sheehan Hope on Deck: do the desk, and I just ask them, because we’ve got, you know, we’ve grown a rapport with them, and just in hopes that one of these days, they’ll say they’re ready. How do we doc… is there any particular way to document that? Like, you know, Joe…
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Dawn Sheehan Hope on Deck: came in.
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Dawn Sheehan Hope on Deck: every week for 12 weeks, in 6 of the weeks we did it, even though he only counts as one, and then he went into treatment. Is there any documentation? Like, and obviously, we’re not going to say Joe, but is there any…
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Dawn Sheehan Hope on Deck: Because I know you guys keep record of, you know, what we do. How should that be documented, is, I guess, my question in a nutshell.
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Amy Shanahan: Hmm.
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Amy Shanahan: That’s a DSAM question about that.
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Sherry Szczuka DSAMH: Yeah, I was waiting for that.
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Amy Shanahan: And maybe I’ll hand the mic over to DSAM to wrap up, yes?
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Sherry Szczuka DSAMH: Yeah, so, yeah, so let’s, get to, to that question and answer. So, some of that depends, Amy, not Amy, Dawn, because what happens is, if you refer them to treatment.
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Sherry Szczuka DSAMH: If you said, hey, Joe, you need to be, you know, you should really seek treatment.
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Sherry Szczuka DSAMH: And if you actually engage with them, and you got a location or a treatment center where they’re looking to do that, then you would report that in your follow-up, that you met them, you know, you engaged with them, and you had follow-up with them.
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Sherry Szczuka DSAMH: If you didn’t get them to… referring them to treatment, you’re still in that discussion phase, then that’s really your… you’re continuing to have a brief intervention with them. You’re continuing to have that conversation with them, and at some point, they’re going to be ready for that referral to treatment.
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Sherry Szczuka DSAMH: So, does that answer the question, Dawn?
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Sherry Szczuka DSAMH: Hopefully.
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Sherry Szczuka DSAMH: Oh my gosh, we lost your… Oof, I… I can’t hear you.
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Victoria Pauline, (she/her) | BBS: She’s shaking her… Dawn was shaking her head, yeah, Sherry.
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Sherry Szczuka DSAMH: Okay.
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Dawn Sheehan Hope on Deck: Yes, that does answer it. Thank you.
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Sherry Szczuka DSAMH: Yeah.
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Sherry Szczuka DSAMH: So, are there any other questions?
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Sherry Szczuka DSAMH: All right, so I think our, our wrap-up and our next steps are, our next session is
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Sherry Szczuka DSAMH: The 29th, 729 at 11 a.m. to 12.
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Sherry Szczuka DSAMH: Nude.
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Sherry Szczuka DSAMH: I think I got that right, so it’s the next two weeks, we’re going to get you for another hour, we’re going to build on this conversation, and we are going to tell you that you have an opportunity, should you have any questions.
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Sherry Szczuka DSAMH: or anything regarding this training or this session, reach out to your program integrity specialist, drop an email to the ORT mailbox.
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Sherry Szczuka DSAMH: whatever works for you, but engage with us, and we’ll help you through it. Don’t feel like you need to wait for another meeting to do this.
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Sherry Szczuka DSAMH: So, I thank you for your cooperation, and do we have a… Do we have a,
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Sherry Szczuka DSAMH: A post-session evaluation, Victoria, usually?
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Victoria Pauline, (she/her) | BBS: We’re working on getting that updated, and we’ll send it out in the, follow-up email.
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Sherry Szczuka DSAMH: Okay, very good. So you guys are going to have a little bit of homework, when you receive the email, just a…
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Sherry Szczuka DSAMH: a brief survey of, you know, process improvements for us, what you liked, what you didn’t like. I think it’s maybe 5 questions, I think? So please, if you could engage in that, I appreciate all your time, energy, and effort with joining this conversation today and this session, and we’ll look forward to seeing you next week.
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Sherry Szczuka DSAMH: And if there are no other questions.
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Sherry Szczuka DSAMH: You may all feel free to…
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Sherry Szczuka DSAMH: drop, and we will get the presentation to you, in the next day or so. Might even be this afternoon, I’m not sure.