David Jefferson, MSW
Director of Training and Technical Assistance
Northwest ATTC

Over the past three years, in collaboration with the Northwest ATTC, I have led a large technical assistance project to support implementation of Motivational Interviewing (MI) for 200+ members of the behavioral health workforce employed at social service agencies in Whatcom County, Washington. During the course of this targeted technical assistance project, workforce members participated in basic and intermediate MI training workshops and received individualized, skills-focused coaching. In March 2020, when I became the Director of Training and Technical Assistance at the Northwest ATTC and we found ourselves in the midst of the pandemic, with providers being asked to quickly pivot to telehealth, it seemed like the perfect opportunity to build on their MI skills.

In mid-March, local programs discontinued face-to-face sessions and their workforce started providing all services virtually (i.e. phone, video-conferencing). Knowing we had a robust number of MI-trained workforce members, we thought this would be an opportune time to offer them individualized coaching in applying MI in their telehealth services. We speculated workforce members needed to increase their confidence in providing care, needed skills in this new medium, and could use guidance on how to be more effective with MI. We also knew many programs would be overwhelmed with administrative and programs complications related to Covid-19.

In response to this need, the Northwest ATTC developed a MI telehealth coaching protocol and by early April started delivering individualized coaching sessions to 41 workforce members. The coaching sessions were 30 minutes in length and delivered via Zoom. Prior to each coaching session, workforce members filled out a skill development form, which included identifying skills they were interested in developing, and writing out a case scenario. During the sessions, the coach role-played the client and the workforce member practiced his or her skills. The sessions ended with a debrief about what worked well, what were the challenges, and what skills to improve. Workforce members were offered up to four individual coaching sessions, and most completed at least three. In all, we completed 99 coaching sessions through the end of May.

The coaching revealed a depth of dedication and commitment by workforce members, who signed up to advance their skills during a time when their stress was peaking, workloads were more complicated and certainty in their day-to-day lives, hard to find. Workforce isolation prompted us to invite all participants to a one-hour Zoom session with the goal of sharing lessons learned and strengthening community. We asked the 25 attendees to answer three questions in small groups and report their top impressions. Here are the questions and responses.

What have you learned to improve your Telehealth services?
  • Workforce members benefit from setting up a workspace, being prepared to provide guidance and structure for the call and taking responsibility for setting the tone.
  • It is important to start calls by checking in about the basics. Asking the client initial questions like: “is this still a good time?”, “are you in an appropriate location?”, and “do you have privacy?” was critical, prior to exploring their comfort and skill level around using the phone and/or computer for services.
  • Acknowledge the common awkwardness, empathize with your shared dilemma of this new medium, and use humor to defuse the situation.
  • Adjust to shifting goals and respect the silence, not all clients like to talk on the phone.

What MI skills have been most useful?
  • The Four Processes of MI; Engagement, Focusing, Eliciting and Planning are helpful for structuring the call and guiding the conversation.
  • Slowing down helps clients make faster connections
  • Moving away from my “to-do list” and developing an agenda with the client.
  • Open-ended questions and reflection keep the conversation going but the reflections need to be deeper and lean toward what is possible, what is helpful, and what is hopeful.
  • Meaningful and well-crafted affirmations shine a light on clients’ skills and abilities especially during these times when they feel desperate and stagnant. Affirming that they have the resources to go forward helps them identify their self-efficacy.
  • Summaries help start and end the conversations and add structure. They create a story or narrative about the client’s life that is difficult to capture in these two-dimensional settings.
  • Explore the discord, as it helps increase engagement.

What are your pending challenges to strengthen services?
  • Building rapport and making genuine connections over the phone is the hardest part. Not all clients are comfortable with using phones for counseling sessions and do not see the value.
  • Maintaining connections via virtual sessions is hard and must be attended to each time.
  • Ambivalence is on the increase. Everything seems to be put on hold. Encouraging change talk is a bit harder as clients are hesitant to move on, due to fear, etc. (e.g., some have chronic diseases are afraid to go to healthcare providers).
  • They want Covid-19 information, which is limited, so it triggers the desire to fix clients and leaves workforce members feeling like they did not help.
  • Hard to move people to the eliciting phase. Need to make use of looking forward strategies to build hope and rekindle dreams.

Offering this cohort an opportunity to practice their MI skills with mock client role-plays, seemed well timed, and many expressed their appreciation and gratitude. The success of the project led the Northwest ATTC to offer the same opportunity starting in late May to the Idaho behavioral health workforce and we are exploring the possibility of expanding in other areas in region Ten.


Addressing the Syndemic of Addiction, COVID-19, and Structural Racism by Strengthening the Workforce



By Sara Becker 
New England ATTC

According to the latest data from the Centers for Disease Control and Prevention, over 105,000 Americans have died and at least 1.7 million Americans have been infected with the novel coronavirus disease (COVID-19). Social distancing measures put in place to contain the spread have decimated entire sectors of the United States economy, with the stock market dropping so precipitously that it erased three years of gains. Unemployment rates are also at historically high levels with the national rate rapidly approaching 15%. In a few short months, COVID-19 has upended our country and harmed millions of Americans.

Data on the toll of COVID-19 are troubling in aggregate, but even more concerning when we consider those Americans hit the hardest. Recent commentary by NIDA director Nora Volkow (2020) underscored how individuals who use opioids are at increased risk for the most adverse consequences of COVID-19 due to both direct (e.g., slowed breathing due to opioid use) and indirect (e.g., housing instability, incarceration) pathways. In addition, Black Americans and Hispanics have been disproportionately affected by COVID-19: emerging regional data suggests that the COVID-19 death rate for Black and Hispanic Americans is about 2.5 times higher than for whites. The disproportionate toll of disease reflects the effects of structural racism, which manifests in increased risk of underlying health conditions (e.g., chronic respiratory disease); decreased access to testing and care; and decreased ability to socially isolate due to factors such as crowded living conditions and employment in sectors deemed essential. Taken together, these data indicate that the United States is in the midst of a syndemic - defined as the interaction of a set of linked health problems involving two or more conditions, interacting synergistically and contributing to excess burden of disease. Addressing the syndemic of addiction, COVID-19, and structural racism requires responses on multiple levels and across multiple fronts. One of those fronts is ensuring that the addiction treatment workforce is equipped with the tools needed to help patients facing these interacting epidemics.

The Addiction Technology Transfer Center (ATTC) Network has been working to meet this challenge by developing new products and resources focused on these intertwined public health issues. The National Coordinating Office hosted a Listening Session and a 5-part Strategic Discussion Series focused on emerging issues around COVID-19 and social determinants of health. The Listening Session solicited feedback on ways COVID-19 has highlighted racial and ethnic disparities, and each Strategic Discussion focused on concrete actions that could be taken to support specific communities of color.

Regional ATTCs have also risen to the challenge to create new tools for the addiction workforce during these unprecedented times. The New England ATTC has developed multiple products including a 2-part webinar series (in partnership with the New England Mental Health Technology Transfer Center) focused on the intersection of addiction, mental health, and COVID-19; a training focused on Trauma-Informed Approaches to Substance Use Assessment and Intervention (which includes new content on how to sensitively assess and address the trauma of racism and the traumas inflicted by COVID-19); and a workshop on Cultural Intelligence and Cultural Humility (which has been adapted to address the disparities and racism highlighted by COVID-19). The New England ATTC has also partnered with the South Africa HIV ATTC to develop a series of products focused on provider self-care in recognition of the toll that caretaking places on front-line health professionals. Finally, in October 2020 the New England ATTC will proudly host this year’s national Addiction Health Services Research Conference (delivered fully virtually)! One of the plenary talks by Dr. Ayana Jordan will specifically address the intersection of structural racism and addiction, and spotlight awards will be given to addiction researchers from underrepresented minority groups.

The New England ATTC is proud to join other Regional ATTCs in not only building the skills of the SUD workforce but also providing supportive strategies for sustaining hope and encouraging self-compassion during this trying times. Please visit the New England ATTC’s COVID-19 resource page to see the latest products and training events devoted to addressing this syndemic.

How to Reduce No-shows to Virtual Appointments

Todd Molfenter, Ph.D.
Director, Great Lakes ATTC, MHTTC, and PTTC

Is this a familiar scenario for your organization?

Day 1: Stay-at-home order: Your agency enacts social distancing guidelines.

Day 3: Your agency has switched in-person counseling to telephonic or video-based counseling.

Day 12: Virtual services, particularly telephone, have increased engagement rates!

Day 30: The honeymoon is over: show rates to virtual appointments are decreasing, especially among new consumers.

In the COVID-19 era, an old nemesis has returned: appointment no-shows. While telehealth has removed some barriers to behavioral health services, other engagement challenges are emerging. Agencies can take the “how exactly are we going to do this?” approach that COVID-19 has thrust us into since the beginning.

Another way is to turn to existing tools and proven practices to address the new no-show dilemma.

Three Tips to Reducing No-Shows During COVID-19 and Beyond
Apply these three tips, in this order, and watch your no-show rates decrease and show-rates increase.


1. Track No-Show Performance 

You can’t improve what you do not measure. No-shows should be measured. Measure no-shows to virtual appointments the same way you measured no-shows to in-person appointments before COVID-19. Compare no-show rates pre- and post- COVID. Segment the data as needed: new vs. existing client; by client age; by appointment type, etc. This measurement creates a foundation for improvement.

2. Use PDSA Cycles!

The Plan-Do-Study-Act (PDSA) method creates a simple process to test new approaches and observe their impact on no-shows. (See related post from NIATx coach Mat Roosa: Learning from Crisis: PDSA in Times of Challenge.) Plan a change; Do a change; Study the impact of the no-shows; then, Act on the change. (Adopt, adapt, or abandon.) You can conduct PDSA Cycles as part of an organized agency-based improvement initiative. Or, individual clinicians can perform PDSA cycles to improve their show rates.

What are good practices for addressing no-shows in a PDSA cycle? See Tip 3:

3. Use Proven Practices to Reduce No-shows
While COVID-19 provides us with some very new situations, we can learn a lot from what’s worked in the past to reduce no-shows.

Open scheduling: Book appointments to accommodate consumers’ schedules. Evening hours? Weekend hours? Ask the consumer, “When would you like us to talk next?”

Reminder calls, e-mails, and text messaging work for virtual appointments as well as they do for in-person appointments. Note the scheduling of the reminder message or text: Two days prior seems to work best for in-person appointments; one day before or on the day of for virtual appointments.

Evidence-Based Practices to Reduce No-Shows

Use Motivational Interviewing (MI) to reduce no-shows by increasing the consumer’s interest in coming back. The growing evidence base for MI shows its effectiveness in a variety of settings.

Use incentives or Contingency Management. Contingency Management is proving to be an effective EBP to enhance retention, particularly for stimulant use disorders. Offer consumers an incentive to reward attendance: a recognition certificate, gift card, or other small prizes.

Learn more about Motivational Interviewing and Contingency Management through the free online courses available through HealtheKnowledge, the ATTC Network’s online learning portal.

Patient no-show trend analysis can identify high-risk no-show patient categories (new vs. existing patients, payer source, patient age) as well as situations (day of the week, time of day, location). Develop patient scheduling practices to increase show rates from identified areas. This practice is particularly relevant as we need to understand better when, where, and how virtual appointments have greater participation.

Interested in learning more about how you can use these tips to reduce no-shows in your organization? Watch for information on the new Virtual NIATx Change Leader Academy—details available soon on the Great Lakes ATTC, MHTTC, and PTTC websites.

What have you found most useful in increasing participation in virtual care? What conditions and practices hurt appointment attendance? What have helped? Let us know in the comment section below.


Dr. Todd Molfenter is the deputy director of the Center for Health Enhancement Systems Studies at the UW-Madison. He is also the director of three SAMHSA-funded Technology Transfer Centers: the Great Lakes Addiction Technology Transfer Center, Mental Health Technology Transfer Center, and Prevention Technology Transfer Center. Todd specializes in implementation science, with a particular focus on technology and evidence-based practices in behavioral health.

South Southwest ATTC: Implementing Remote Technology In a Time of Crisis




Maureen Nichols
Director, South Southwest Addiction Technology Transfer Center
HHS Region 6

The recent COVID-19 health pandemic has accelerated the implementation of behavioral health services via remote technology, including telephone and video conferencing. In March 2020, as behavioral health treatment and recovery organizations prepared to continue critical services while implementing social distancing guidelines needed to keep patients and staff safe and healthy, many turned to the use of technology as a solution, including video conferencing and telephone services. For organizational leadership, decisions around critical issues such as compliance with laws and best practices related to patient confidentiality and protection, choice of platforms, licensing and certification regulations for practitioners, and costs and reimbursement procedures, had to be made at an accelerated rate. Federal and state agencies began issuing guidance related to relaxation of enforcement of privacy protections in a limited way due to the short-term health crisis, and funders addressed modifications to reimbursement policies to include telehealth services. However, much of the guidance was necessarily high level, leaving leadership of individual behavioral health programs to assess the fiscal and practical ramifications of responding to the new service landscape via the use of telehealth in the both the short and long term.


Over the past several years, the South Southwest Addiction Technology Transfer Center, in partnership with National Frontier and Rural Telehealth Education Center (NFARtec), has been offering training and technical assistance to states, tribal communities and behavioral health organizations and practitioners as part of its telehealth initiative. This includes documenting best practices and real world examples of implementation, such as the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) successful initiative to increase the uptake of telehealth technologies to deliver assessment, treatment and recovery services in their public health system. It also includes offering behavioral health clinicians and peer support specialists learning collaborative opportunities to build and practice their videoconferencing skills and receive coaching and feedback from experienced behavioral health telehealth practitioners.


At the start of the response to the pandemic, South Southwest ATTC began receiving multiple requests from organizations across the region for immediate guidance on how to translate many of the strategies for remote technology on the ground in a rapid and timely manner. SSW ATTC facilitated regional dialogues between state and local behavioral health organizations with telehealth experience and organizations new to the use of remote technology, including an event in Oklahoma with tribal communities, experienced behavioral health providers and ODMHSAS. Through those discussions, it became apparent that concrete guidance on practical steps for organizations to take in order to implement remote technology was needed. As a result, SSW ATTC developed the Framework for Implementation of Telehealth Services in a Behavioral Health Setting in a Short Time Frame, which covers topics that include:

  • Determining participant interest and capacity for use of technology
  • Selection of technology platforms
  • Patient safety and privacy considerations
  • Staff support and training
  • Review of internal policy and procedures
  • Adapting work flows
  • Fiscal considerations and reimbursements

The goal is to provide a framework for behavioral health care providers that guides organizational leadership through short term practical steps for implementation of remote services via technology while including successful long-term strategies for sustaining telehealth services.





This guide is one piece of a regional and national TTC network partnership designed to provide resources and support to the behavioral health field to ensure services to individuals in our community are accessible, evidence based and culturally responsive during the current challenging health crisis and beyond. Additional resources from the TTC network are available at attcnetwork.org, mhttcnetwork.org and pttcnetwork.org. To access regional assistance from the South Southwest Addiction Technology Transfer Center, please contact us via website or email.


Share Your Perspectives about Opioid Use Disorder among People with Disabilities from Minority Backgrounds




Share Your Perspectives about Opioid Use Disorder among People with Disabilities from Minority Backgrounds.Please click or cut and paste survey link below to participate:

https://www.psychdata.com/s.asp?SID=189204

We are pleased to invite substance, mental health service and vocational rehabilitation professionals (e.g., counselors, clinicians, directors) from across the country that provide to participate in a national study on Opioid Use Disorder Impacts on Employment Prospects for People with Disabilities from minority backgrounds (i.e., African American, Hispanic or Latino, American Indian, Alaskan Native, or Native Hawaiian or other Pacific Islanders). Opioid use disorder (OUD) can involve maladaptive/misuse of prescribed opioid medications, use of diverted opioid medications, or use of illicitly obtained heroin.

This study is being conducted by The Langston University Rehabilitation Research and Training Center (LU-RRTC) on Research and Capacity Building for Minority Entities. Langston University is the only historically black college or university (HBCU). The LU-RRTC is funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR).

The new information generated through this study would provide insights on how policy makers, educators and federal research sponsoring agencies such as the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and the National Institutes of Health (NIH) can better respond to the needs of people with opioid use disorder, especially people with disabilities from minority backgrounds. In addition, the study findings may be used as a foundation for developing interventions that seek to improve the experiences and outcomes of individuals with disabilities from minority backgrounds with opioid use disorder.

The information in this study will be used only for research purposes and in ways that will not reveal who you are. Study participants will not be identified in any publication from this study. The survey will take around 20 minutes to complete. If you have any questions or concerns, please contact Dr. Corey Moore (Principal Investigator) via email: corey.moore@langston.edu or Dr. Edward Manyibe (Co-PI) via email: manyibe@langston.edu. If you experience technical difficulty with the survey, contact Dr. Andre Washington: andre.washington@langston.edu and he will be happy to assist you.

Please click or cut and paste survey link below to participate:

https://www.psychdata.com/s.asp?SID=189204

Thank you in advance for your contribution.