New Application: Addiction Medicine

New Application: Addiction Medicine

Training & Accreditation Committee

The Addiction Medicine Foundation

Instructions

All text boxes in this form may be expanded as necessary.

Include the following attachments (labeling each by number):

1. Program Letter of Agreement (PLA) for each participating site in which fellows receive required training.

2. Program Director and physician faculty CVs.

3. Overall educational goals for the program.

4. Policy for supervision of fellows (addresses fellows’ responsibilities for patient care and progressive responsibility for patient management and faculty responsibilities for supervision).

5. Program policies and procedures (duty hours, work environment, moonlighting, due process).

6. Copies of instruments that will be used:

6a. by faculty to evaluate fellows at the completion of each assignment

6b. by faculty to evaluate fellows at the completion of training

6c. by fellows to evaluate faculty and the program.

Please email the application and attachments to:

AND

Mail the signed application form to:

Andrew Danzo

University at Buffalo Dept. of Family Medicine

77 Goodell Street, Suite 220

Buffalo, NY 14203

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New Application: Addiction Medicine

Training & Accreditation Committee

The Addiction Medicine Foundation

Sponsoring Institution [I.A]

Sponsoring Institution Name*
ACGME Code (sponsor number)
Designated Institutional Official

*Enter name as it appears on the ACGME listing of sponsoring institutions:

Fellowship

Fellowship Program Name
Mailing Address / Telephone
E-mail / Web address
Number of fellowship positions requested
Planned start date for first fellow(s)
Name of the residency program(s) with which the fellowship is associated [I.A.2 & 3]
Residency Program Director

Is funding currently available to support fellow(s) [NOTE – funding for fellows is not required by TAMF at time of accreditation] ☐YES ☐NO

If funding is available:

How many fellows will it support?
What is the source(s) of funding?

Signatures

Designated Institutional Official
Name / Signature / Date
Fellowship Program Director
Name / Signature / Date

Participating Sites [I.B]

List all clinical sites where fellow training will occur. Attach a copy of the Program Letter of Agreement for all sites that provide a required assignment and are not under the governance of the sponsoring institution.

Site 1: Primary Teaching Site
Name
Address
Is site under governance of the sponsoring institution? / ☐YES ☐NO
Duration of experience at this site (total for all rotations, in months or weeks)
Briefly describe the content of the educational experience at this site, addressing faculty coverage, volume/variety of clinical experience, and educational impact (up to 250 words)
Site 2
Name
Address
Is site under governance of the sponsoring institution? / ☐YES ☐NO
Is the experience at this site / ☐REQUIRED ☐ELECTIVE ☐BOTH
Duration of experience at this site (total for all rotations, in months or weeks)
Briefly describe the content of the educational experience at this site, addressing faculty coverage, volume/variety of clinical experience, and educational impact (up to 250 words)
Site 3
Name
Address
Is site under governance of the sponsoring institution? / ☐YES ☐NO
Is the experience at this site / ☐REQUIRED ☐ELECTIVE ☐BOTH
Duration of experience at this site (total for all rotations, in months or weeks)
Briefly describe the content of the educational experience at this site, addressing faculty coverage, volume/variety of clinical experience, and educational impact (up to 250 words)

Copy and add additional Participating Site boxes as needed, numbering consecutively.

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Program Personnel and Resources

Program Director [II.A]

Does the Program Director have a minimum of 0.1 FTE protected time to carry out the educational, administrative, and leadership responsibilities of the fellowship? ☐YES ☐NO

Explain if “NO”:

Has a current CV been enclosed with application?...... ☐YES ☐NO

Name, Degree(s)
Department
Faculty Rank
Mailing Address
E-mail / Phone (office) / Phone (mobile)
Primary Specialty (ABMS)
Subspecialty (ABMS)
Addiction Medicine certification / ☐CURRENT ☐PENDING ☐NEITHER
Addiction Psychiatry certification / ☐CURRENT ☐PENDING ☐NEITHER
If you do not have addiction certification but are certified in another subspecialty that incorporates training in addiction medicine, what is that subspecialty?

Physician Faculty

(add rows if needed)

Name, Degree(s) / Department and Rank (eg, Prof, Clinical Asst Prof, etc) / Primary Board Certification(s) / Subspecialty certification(s)*

* In addition to the program director, there must be at least one other physician faculty with current or pending certification in addiction medicine, addiction psychiatry, or in another subspecialty that incorporates training in addiction medicine. [II.B.1.a]

Describe faculty scholarly activities, such as research, publication and participation in specialty societies, [II.B.5a]

Will faculty regularly participate in organized clinical discussions, rounds, journal clubs and conferences [II.B.5b] ☐YES ☐NO

Other Program Personnel

Coordinator

Name / Phone / E-mail

Will clinicians with expertise in the proper evaluation and management of pain conditions be available [II.C.3] ☐YES ☐NO

Will fellows train in settings where there is meaningful clinical interaction, collaboration and consultation with residents, fellows, faculty and staff [II.C.4] ☐YES ☐NO

Duty Hour, Patient Safety, and Learning Environment [VI]

Excluding call from home, what is the projected average number of hours on duty per week per fellow, inclusive of all house call and all moonlighting?[VI.G.1]

Program Resources

How will the program ensure that faculty (physician and non-physician) have sufficient time to supervise and teach fellows? Mention time spent in activities such as conferences, rounds, journal clubs, etc. if relevant [II.B.2]

Briefly describe the educational and clinical resources available for fellow education. [II.D. & III.B.]

Fellow Appointments

Briefly describe how the program will handle complaints or concerns fellows raise with faculty members or the program director (describe how this can be done in a confidential and protected manner).

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Educational Program

Will the program distribute the overall skills and competencies to fellows and faculty at least annually? [IV.A.1] ☐YES ☐NO

Patient Care and Procedural Skills [IV.A.2.a]

Will fellows be expected to demonstrate:

Competence in comprehensive assessment, diagnosis and treatment of patients with substance-related health problems, substance use disorders and other addictive disorders, along a continuum of care including inpatient/residential, outpatient treatments, early intervention, harm reduction and prevention ☐YES ☐NO

Competence in providing care to patients in different settings such as inpatient medically managed withdrawal programs, substance use disorder treatment programs, consultation services and integrated clinics ☐YES ☐NO

Competence providing care to substance use disorder patients with diversity in age, gender, socio-economic status, limited English proficiency or literacy,and co-morbid medical and psychiatric conditions ☐YES ☐NO

Proficiency in screening, brief Intervention, and motivational interviewing...... ☐YES ☐NO

The ability to work with aninterdisciplinary team that could include other medical specialists, health care providers, counselors, psychologists, family members and other stakeholders involved in the patient’s care ☐YES ☐NO

The ability to provide continuity of care to patients...... ☐YES ☐NO

Explain any “NO” response (up to 150 words per “NO” response):

Medical Knowledge [IV.A.2.b]

Will fellows be expected to demonstrate a level of expertise in the knowledge of those areas appropriate for a subspecialist in addiction medicine, including basic science, prevention, screening, brief intervention and referral, assessment and diagnosis, treatment planning and management? ☐YES ☐NO

Will fellows be expected to demonstrate a level of expertise in the knowledge of:

The medical model of addiction, including a basic knowledge of neurobiology and changes in brain structures associated with addiction ☐YES ☐NO

Pharmacology of common psychoactive substances, including alcohol, nicotine, stimulants, sedative-hypnotics, depressants, opioids, inhalants, hallucinogens, and cannabinoids ☐YES ☐NO

Epidemiology of substance use and use disorders and the genetic and environmental influences on the development and maintenance of these disorders ☐YES ☐NO

The impact of substance use in diverse populations and cultures, including women, neonates, children, adolescents, families, the elderly, injury and trauma, military, health care professionals, employees, and/or persons involved in the criminal justice system ☐YES ☐NO

Common behavioral addictions ...... ☐YES ☐NO

Prevention, including identification of risk and protective factors...... ☐YES ☐NO

Screening, brief intervention strategies appropriate to substance use risk level, and referral to treatment ☐YES ☐NO

Comprehensive substance use assessment including diagnostic interview, use of standardized questionnaires, lab tests, imaging studies, physical examinations, mental status examinations, consultative reports and collateral information ☐YES ☐NO

Identification and treatment of common co-occurring conditions such as medical, psychiatric and pain ☐YES ☐NO

Matching patient treatment needs with levels of intervention including crisis services, hospitalization, SUD treatment programs ☐YES ☐NO

Medication assisted therapies and psychosocial interventions for SUD’s across the age spectrum ☐YES ☐NO

Intoxication and withdrawal management: the mechanisms of alcohol, sedatives, opioids and other drugs, and the pharmacotherapies and other modalities used to treat these………… ☐YES ☐NO

The safe prescribing and monitoring of controlled medications to patients with or without substance use disorders, including experience accessing and interpreting prescription drug monitoring systems ☐YES ☐NO

The effects of substance use, intoxication, and withdrawal on pregnancy and the fetus, and the pharmacologic agents prescribed for the treatment of intoxication, withdrawal and management, including specifically opioid and sedative hypnotic withdrawal ☐YES ☐NO

Explain any “NO” response (up to 150 words per “NO” response):

Practice-based Learning and Improvement [IV.A.2.c]

Briefly describe how fellows will develop skills and habits to systematically analyze practice using quality improvement methods, implement practice improvement, and utilize scientific evidence related to patient health. (up to 400 words)

Interpersonal and Communication Skills [IV.A.2.d]

Will fellows be expected to:

Work collaboratively with other providers and allied health professionals, including physicians, nurses, social workers, counselors, and pharmacists to care for patients with substance-related disorders ☐YES ☐NO

Work collaboratively as members of inter-disciplinary teams as a consultant and as a team leader ☐YES ☐NO

Demonstrate competence in interviewing socioculturally-diverse patients and families in an effective manner which may include those with limited English proficiency, literacy, hearing, sight ☐YES ☐NO

Explain any “NO” response (up to 150 words per “NO” response):

Professionalism [IV.A.2.e]

Will fellows be expected to:

Demonstrate competence in recognizing and appropriately addressing biases in themselves, others, and the health care delivery system ☐YES ☐NO

Demonstrate maintenance of appropriate professional boundaries...... ☐YES ☐NO

Demonstrate sensitivity and responsiveness to diverse patients, including sex, age, culture, race, religion, disabilities,and sexual orientation ☐YES ☐NO

Demonstrate compassion, integrity, and respect for others...... ☐YES ☐NO

Demonstrate the qualities required to sustain lifelong personal and professional growth

...... ☐YES ☐NO

Develop the ability to use self-awareness of knowledge, skills, and emotional limitations to engage in appropriate help-seeking behaviors ☐YES ☐NO

Demonstrate healthy coping mechanisms to respond to stress...... ☐YES ☐NO

Manage conflict between personal and professional responsibilities...... ☐YES ☐NO

Practice flexibility and maturity in adjusting to change with the capacity to alter one’s behavior

...... ☐YES ☐NO

Demonstrate trustworthiness that makes colleagues feel secure when one is responsible for the care of patients ☐YES ☐NO

Provide leadership skills that enhance team functioning, the learning environment, and/or the health care delivery system ☐YES ☐NO

Demonstrate self-confidence that puts patients, families, and members of the health care team at ease ☐YES ☐NO

Recognize that ambiguity is part of clinical health care and respond by utilizing appropriate resources in dealing with uncertainty ☐YES ☐NO

Explain any “NO” response (up to 150 words per “NO” response):

Systems-based Practice [IV.A.2.f]

Will fellows be expected to demonstrate the ability to:

Advocate for quality patient care and assist patients, employers, programs, agencies and governments in managing system complexities, including an awareness of heightened stigma associated with addiction and other systemic barriers to obtaining addiction services. ☐YES ☐NO

Explain how medical practices and delivery systems differ from one another, including methods of controlling health care costs and allocating resources and practice and promote cost-effective health care. ☐YES ☐NO

Explain any “NO” response (up to 150 words per “NO” response):

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Curriculum Organization and Fellow Experiences [IV.A.3]

Enter the approximate number of hours per month (and total in last column)

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / Total
Outpatient rotations
Inpatient rotations
Electives
Continuity Outpatient
Learning Experience

Clinical Rotations: Outpatient

Will fellows have at least 3 months cumulative of outpatient experience [IV.A.3(2)].....☐YES ☐NO

Explain if “NO” (up to 400 words):

Outpatient Rotation 1
Rotation Name / Clinical Site (Name and #) / Length / Faculty supervising
Briefly describe the training experience, including setting, activities, patients (up to 300 words)

Copy and add Outpatient Rotation boxes as necessary

Clinical Rotations: Inpatient

Will fellows have at least 3 months cumulative of inpatient experience [IV.A.3(3)].....☐YES ☐NO

Explain if “NO” (up to 400 words):

Inpatient Rotation 1
Rotation Name / Clinical Site (Name and #) / Length / Faculty supervising
Briefly describe the training experience, including setting, activities, patients (up to 300 words)

Copy and add Inpatient Rotation boxes as necessary

Longitudinal Continuity Outpatient Experience

Will fellows have at least 1 half-day per week providing continuity care to a panel of patients who have an addiction disorder [IV.A.3(3)] ☐YES ☐NO

Longitudinal Continuity Outpatient Experience
Clinical Site (Name and #) / Faculty supervising
Briefly describe the training experience, including setting, activities, patients (up to 300 words)

Scholarly Activities

Will the program provide a supervised, ongoing forum in which fellows explore and analyze emerging scientific evidence [IV.B.2.a] ☐YES ☐NO

Will the program provide fellows with didactic and experiential learning in the scholarship of teaching and leadership [IV.B.2.b] ☐YES ☐NO

Will fellows have the opportunity to teach addiction medicine to health care students, trainees and/or professionals [IV.B.2.b] ☐YES ☐NO

Will fellows actively participate in research or scholarly projects that make use of scientific methods [PR.IV.B.2.c] ☐YES ☐NO

Will the program provide fellows with didactic and experiential learning in leadership [IV.B.2.d] ☐YES ☐NO

Longitudinal Learning Experience

Will fellows have at least 4 hours per week devoted to longitudinal learning experiences [IV.A.3 (1)]

...... ☐YES ☐NO

Please describe (no more than 400 words)

Electives & Program-directed Activities

Will fellows spend the remaining time that is not dedicated to outpatient rotations, inpatient rotations, continuity outpatient experience and longitudinal learning experiences in electives and program-directed activities [IV.A.3(4)] ☐YES ☐NO

If “NO” explain (up to 400 words)

Identify electives offered:

Name / Site # / Length (weeks) / Faculty supervising / Brief description (up to 300 words per elective)
1
2
3
4
5

Add rows if needed (number consecutively)

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Evaluation

Briefly describe how the program director and faculty will evaluate fellow abilities in order to determine progressive authority and responsibility, conditional independence and a supervisory role in patient care [VI.D.4] (up to 400 words)

Identify the program faculty on the Clinical Competency Committee (minimum 3) [IV.A.1.a]:

Will faculty discuss evaluations with fellows at least every 3 months [V.A.2.a]...... ☐YES ☐NO

Will fellows have the opportunity to provide confidential written feedback of supervising faculty at the end of each rotation [V.B.2] ☐YES ☐NO

Identify the program faculty on the Program Evaluation Committee (minimum 2) [V.C.1.a).(1)]

Using the table on the next page (add rows as needed):

Provide the methods of evaluation used for assessing fellow competence in each of the six required ACGME competencies and identify the evaluators for each method (e.g., “performance in patient care is evaluated by global forms completed by faculty, observed histories and physicals by the ward attending and the continuity preceptor; medical knowledge is assessed through an open-book in-training examination and an evidence-based journal club evaluated by the PD, etc.”)

Examples of assessment methods: direct observation, videotaped/recorded assessment, global assessment, simulations/models, record/chart review, standardized patient examination, multisource assessment, project assessment, patient survey, in-house written examination, oral exam, objective structured clinical examination, structured case discussions, anatomic or animal models, role-play or simulations, formal oral exam, practice/billing audit, review of case or procedure log, review of patient outcomes, review of drug prescribing, fellow experience narrative and any other applicable assessment method

Examples of types of evaluators: self, Program Director, medical student, faculty member, nurse, allied health professional, patient, other residents/fellows, technicians, clerical staff, evaluation committee, consultants

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Competency / Assessment Method(s) / Evaluator(s)
Patient Care
Medical Knowledge
Practice-based Learning & Improvement
Interpersonal & Communication Skills
Professionalism
Systems-based Practice
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