Programs

Clinical Rotation Description

Montefiore Medical Center – Substance Abuse Treatment Program (SATP)/New Directions Recovery Center (NDRC) -- Required, 3-month rotation, 0.6 fte. 

Program/Site Description

Montefiore Medical Center, University Hospital for the Albert Einstein College of Medicine is the primary teaching center for the Albert Einstein College of Medicine Addiction Psychiatry Fellowship.

The Substance Abuse Treatment Program (“SATP”), established in 1972, is a clinical service program operated by the Department of Psychiatry and Behavioral Sciences at Montefiore Medical Center, the university teaching hospital of the Albert Einstein College of Medicine.  The SATP has two opioid treatment programs (Unit I and Unit III) providing medication assisted treatment, together with comprehensive substance abuse treatment services and on-site general and HIV-related primary care and mental health treatment to over 1000 opioid dependent adults.  The SATP also operates a medically supervised outpatient treatment program, New Directions Recovery Center (NDRC), for nearly 60 adults with abuse or dependence to various substances and for significant others/loved ones directly impacted by substance abuse or dependence.  The programs receive funding from the NYC Dept. of Health and Mental Hygiene and the AIDS Institute.  Multiple agencies have regulatory oversight of the programs, including the NYC Dept of Health and Mental Hygiene, Office of Alcoholism and Substance Abuse Services (OASAS), NYS Dept of Health, Drug Enforcement Administration, Center for Substance Abuse Treatment, and the Joint Commission.

The patients in the two OTPs are representative of patients enrolled in methadone maintenance programs.  They tend to be male and the average age is 51 years.  The majority of patients have chronic medical conditions such as Hepatitis C and/or HIV as well as DM and HTN.  A significant minority also have comorbid psychiatric disorders such as mood disorders, post-traumatic stress disorder and anxiety disorders.  The patients are also representative of the diverse neighborhoods in which the clinics are located.  The patients at Unit III, located in the Morris Heights are of the Bronx, are 68% Hispanic and 14% African American.  The patients at Unit I, located in the Woodlawn area of the Bronx, are 54% Hispanic and 15% African American.

Educational Goals and Objectives

1. Develop skill with the induction and stabilization of Opioid Maintenance Therapy (OMT), specifically methadone and buprenorphine
   • Understand rationale for and gain experience with dosing for induction
   • Understand rationale for and gain experience with dose adjustments for stabilization, maintenance, and detoxification
   • Be aware of common side effects and drug interactions
    
2. Be able to complete the initial evaluation (psychiatric, medical, psychosocial, and addiction parameters) of new patients to the program [Please note that this includes a basic physical examination and placement of a PPD test.] and to determine level of care for opioid and co-occurring illicit substance uses (e.g., outpatient, medically supervised residential tx, medically managed inpatient tx).
3. The evaluation of patients already in clinic treatment, now requesting psychiatric consultation or seeking consultation at the recommendation of clinic staff
4. NDRC: Evaluation of dual diagnosis patients, the initiation and continuation of psychotropic medications in the treatment of addiction-related, or non-addiction-related psychiatric disorders, and of pharmacological interventions for addictive disorders (e.g. Buprenorphine, antabuse, naltrexone, acamprosate) including for smoking cessation.
5. Become proficient in facilitating therapy groups for patients in recovery

Other Educational Componenets:

6. Follow four MMTP admissions, including progress in treatment, by keeping a brief record of key measures (e.g. dose, primary and secondary substance use, admissions to detox, engagement with medical or psychiatric care)
7. Supervison/feedback with preceptor
8. Observation with counselor
9. Inservices/Teaching

Clinical Rotation Description

Hospital-based Inpatient Drug and Alcohol Detoxification Unit/Chemical Dependency outpatient treatment program - Required, 3-month rotation, 0.6 fte. 

Program/Site Description

Jacobi Medical Center, located in North East Bronx NYC, is a 457-bed Municipal Hospital, level 1 Trauma Center, affiliated with Albert Einstein College of Medicine which has approximately 20,000 admissions annually.

The Comprehensive Addiction Treatment Center (CATC), located within Jacobi Medical Center, is a nationally respected provider for the treatment of substance use disorders. The CATC is comprised of a 16-bed inpatient detox unit and an intensive outpatient program. The detox unit medically supervises patients in withdrawal from opioids, benzodiazepines, and alcohol. Under the supervision of an Attending Psychiatrist, addiction fellows perform medical and psychiatric evaluations on newly admitted patients and direct the medically supervised withdrawal as well as medical and psychiatric care for these patients. Jacobi has also obtained licensure for ambulatory detox which will likely begin in late 2015. The outpatient program is a five-day per week, intensive, harm-reduction program where patients are in various stages of recovery from substance use and co-occurring disorders. While the treatment emphasis is group psychotherapy, addiction fellows will gain experience in augmenting treatment with pharmacological interventions such as Antabuse, Naltrexone, and Buprenorphine. Addiction fellows work as part of an interdisciplinary team and participate in a broad array of treatment modalities.

CATC currently serves as a training site for ALBERT EINSTEIN COLLEGE OF MEDICINE medical students, psychology interns and externs, social work students, Touro College physician assistant students and Montefiore PGY4 residents taking addiction elective. CATC will be the site for the detox component of the Montefiore PGY2 Addiction Psychiatry Rotation.

Demographics of the Patient Population

The Detoxification Unit admits approximately 930 patients annually. The patient population is diverse (approximately 30% African-American, 50% Hispanic, and 20% Caucasian. The detox unit treats Alcohol, Benzodiazepine and Opioid dependent patients, amongst others (cocaine, K2, cannabis etc). Such diverse patient population provides fellows the opportunity to treat a wide range of substance abuse problems. The service utilizes medical detoxification, individual and group counseling, health education, 12-step meetings, and motivational interviewing technique, and cognitive-behavioral therapy. 70% of patients have psychiatric and medical co-morbidities. CATC will be a site for the Detox component of the Montefiore PGY2 Addiction Psychiatry Rotation in the near future.

The Chemical Dependency program has a census of over 60 outpatients. The service include individual and group therapy for substance use disorders, and psychiatric evaluation, treatment and medical management. There are specialized groups for trauma survivors (seeking safety) and EMDR treatment for PTSD.

This service consists of three (3) components:

1. Screening of detoxification patients
2. 16-bed Alcohol and Detoxification Unit
3. Outpatient chemical dependency clinic

Educational Goals and Objectives

By the end of the rotation, fellows will be able to medically detoxify patients from multiple drugs of abuse (e.g., opioids, cocaine, alcohol, benzodiazepines) and engage patients in the process of recovery and motivation for change

Educational Methods

Pt screening: Patients arrive to the detox unit in several ways. Most patients arrive from CATC triage. Fellows will become familiar with screening potential Detox patients for appropriateness for Detox admission, with a focus on substance withdrawal symptoms and medical comorbidities. Patients are also transferred from other hospital units or CPEP and the fellow will become familiar with communicating with other MD’s and other hospital staff regarding patient screening for Detoxification.

History and Physicals: Fellows will become familiar with doing a history and physical on admitted patients. The focus will be on getting a good substance abuse history, including past withdrawal symptoms, amount and type of substances used, periods of abstinence, prior treatment, etc. Fellows will also become familiar with the physical sequelae of substance abuse by doing physicals on the unit.

Patient Management and Detox protocols: once patients are admitted to the unit, they are started on a specific detox protocol (Ativan, Librium, clonidine and methadone). Fellows will become familiar with different types of detox modalities and managing the withdrawal syndrome. Fellows will also become familiar with managing psychiatric and medical comorbidities as well as biological treatments for alcohol dependence. Fellows will work within a team of attending physician, the physician assistant, nurses and support staff and make clinical decisions regarding patient care. Fellows will round on a subset of patients with the attending and will follow up on recommended treatments and lab tests. Fellows will have a longitudinal component when they do psychiatric evaluations and follow up care of detox patients referred to the Chemical Dependency clinic.

For patients admitted to the ambulatory detox fellows will become familiar with buprenorphine induction and taper

Group Therapy: Fellows are required to observe or co-lead at least two groups per week. Fellows are supervised by an experienced group therapist.

Grand Rounds: Fellows are expected to attend weekly Departmental Grand Rounds

Journal Club: Fellows will be responsible for presenting a scholarly article to staff once during the rotation.

Fellow Lecture: Fellows will be expected to give a lecture on a topic of interest to staff once during the rotation. This will take place during the Departmental Grand rounds

Administrative: participate in bi-weekly team meetings

Inservice Education: Fellows are required to participate in the inservice education sessions which occur monthly

Clinical Rotation Description

The Addiction Psychiatry Consultation Service in Psychosomatic Medicine - Required, 3-month rotation, 0.6 fte. 

Program/Site Description

Montefiore Medical Center (MMC) serves as a Consultation/Liaison training site in the Addiction Psychiatry program. MMC is a 1,000+ bed facility, one of the nation’s largest centers of Residency and Fellowship training in all medical disciplines. All medical specialties are practiced in this University Hospital for the Albert Einstein College of Medicine. MMC, proper, is located five miles from the Albert Einstein College of Medicine, however, the Weiler Division is a short walk from Albert Einstein College of Medicine. Medical students rotate through all of the major Montefiore departments and affiliates. The neighborhood around the hospital is diverse, both economically and culturally, representing patients of all ages and from all parts of the world. Educational activities undertaken by the medical center and its affiliates span the full arena of biomedical training, including physicians, post-graduate medical education (residents and fellows), nursing, occupational therapy, psychology, and social work. Montefiore Hospital, with its many satellite outpatient clinics, serves as a hub of health care provision for well over 1 million residents of the Bronx borough of New York City.

Clinical Rotation Components

1. Evaluation, consultation, and treatment of:
   1. Patients with primary Substance-related Disorders and their families.
   2. Medical and surgical patients in the emergency department, intensive care units, and general wards of the hospital with acute and chronic Substance-related Disorders, including acute intoxication and overdose.
   3. Psychiatric inpatients with chemical dependencies and co-morbid psychopathology to include a broad range of psychiatric diagnoses, such as affective disorders, psychotic disorders, organic disorders, personality disorders, and anxiety disorders as well as patients suffering from medical conditions commonly associated with Substance-related Disorders such as hepatitis and HIV/AIDS.
   4. Medication dependent patients with chronic medical disorders/conditions (such as patients with chronic pain)
   5. Evaluation of neuropsychiatric complications of addiction
    
2. Exposure to patients with Substance-related Disorders related to the following substances:
   1. Alcohol
   2. Opioids
   3. Cocaine and other stimulants
   4. Cannabis and hallucinogens
   5. Benzodiazepines
   6. Other substance of abuse, including sedatives, hypnotics, or anxiolytics
   7. Miscellaneous/unusual, e.g., nutmeg, designer drugs, organic solvents/inhalants
    
3. Rotation should provide fellows with experience in evaluating acute and chronic patients in the inpatient setting. There should be an identifiable structured educational experience in neuropsychiatry relevant to the practice of addiction psychiatry that includes both didactic and clinical training methods. The curriculum should emphasize functional assessment, signs and symptoms of neuropsychiatric impairment associated with Substance-related Disorders, and the identification of physical illnesses and iatrogenic factors that can alter mental status and behavior.
4. The program must provide specific experiences in consultation to acute and chronic medically ill patients with Substance-related Disorders who are being treated on emergency, intensive care, medical and/or surgical services of a general hospital. Supervision of addiction psychiatry fellows in their clinical evaluation of such patients, as well as in their consultative role, is essential. The program should provide fellows with the opportunity to function at the level of a specialist consultant to primary care physicians and to intensive care specialists.
5. Experience in working with multidisciplinary teams as a consultant and as a team leader, including the integration of recommendations and decisions from consulting medical specialists and other professionals in related health disciplines.
6. Experience in working with patients who are participating in self-help programs.
7. Experience with opiate replacement therapy.
8. Addiction-related consults are requested by other departments on an ad-hoc basis, so the concept of “caseload” does not easily apply. Addiction Psychiatry Fellows receive 4-8 addiction-related consults per week. The fellow provides initial consultation and follow-up visits. The fellow will make the initial contact with the patient and the referring clinician, and having received supervisory input will be directly providing the consultative input to the requestors.
9. The Addiction Psychiatry Fellows will be given opportunities to develop evidence-based knowledge through exposure to current literature and to formulate and articulate their knowledge through teaching opportunities.

Educational Goals and Objectives

1. Develop greater skills in obtaining an accurate substance use history and making appropriate substance use disorder diagnosis(es).
2. Develop skill in recognizing various stages in patients’ readiness to change addictive behavior.
3. Develop skill in identifying alcohol, opiate, and sedative withdrawal in the medically ill.
4. Develop skill in assisting the house staff in the management of withdrawal states in the medically ill.
5. Gain knowledge in the use of benzodiazepines and other appropriate medical interventions in treating alcohol withdrawal.
6. Gain knowledge in the use of clonidine, methadone, buprenorphine and other medications in treating opiate withdrawal in the medically ill.
7. Gain knowledge in assessing patients for methadone maintenance and the appropriate use of methadone for detoxification in patients who are not on methadone maintenance.
8. Gain knowledge in managing acute and protracted sedative withdrawal states.
9. Gain knowledge in the management of pain in opioid dependent patients.
10. Gain experience in the liaison work involving difficult to manage patients as it relates to their drug use.
11. Gain experience with patients who have severe, disabling, chronic addictions and the psychological and social factors which contribute to the chronicity of the addiction. This includes attention to countertransference issues and how it impacts his/her own and other hospital staffs’ interaction with the patient.
12. Gain experience with addressing relapses and various states of recovery.
13. Learn about the drug treatment resources available in our community and how to make referrals.
14. Gain experience in educating the nursing and medical house staff about issues related to the management of the addicted medically ill patient.

The fellowship's responsibilities while here include:

1. Completing 5 full consultations on patients, as requested by the primary team, per week, including substance use history, psychiatric history, mental status and physical examinations.
2. Discussing diagnostic and treatment considerations with the consulting medical teams.
3. Following up with the patients and medical teams as needed for desired outcomes.
4. Participating in daily rounds, including presenting new patients and reporting developments in previously discussed patients.
5. Providing education to medical students and residents who are on the Addiction Consultation service when possible.

Clinical Rotation Description

Required, 3-month rotation, 0.6 fte. (including Adolescent Track, 0.1 fte.) 

Program/Site Description

The Montefiore Behavioral Health Center @ Westchester Square is under the auspices of Montefiore Medical Center. Currently, MBHC provides services for approximately 3,300 patients and greater than 100,000 patient visits per annum, to patients living in the northeastern section of the Bronx. It services an economically and racially diverse population. Faculty and staff hold appointments at the Albert Einstein College of Medicine. MBHC supports training in nursing, social work and psychology. The Center currently has contracts with the City of New York to provide mental health services and is licensed through the State of New York Office of Mental Health.

Montefiore Behavioral Health Center @ Westchester Square

MICA Component of the Westchester Square Adult OPD is located at 2527 Glebe Avenue in a residential neighborhood in the northeast Bronx. It serves an ethnically and economically diverse population. Currently our patient census is fifty six percent Hispanic and twenty two percent Black. Sixty five percent of the patients are female. Patients range from homeless and without a source of income to middle class in background, but ninety-two percent receive Medicaid. The diagnostic diversity is wide, encompassing a range from severe chronic psychotic disorders to Adjustment Reactions. Most commonly we see mood and anxiety disorders, including Post-traumatic Stress Disorder, schizophrenia spectrum disorders and cluster B personality disorders co-occurring with substance related diagnoses usually involving nicotine, alcohol, opiates, cannabis, sedative-hypnotics and/or cocaine. Clinical services we provide include individual psychotherapy, group psychotherapy, family interventions, cognitive-behavioral modification techniques, psychopharmacology, and consultation-liaison. Child OPD is also located at Westchester Square.

Adolescent Outpatient Program (0.1 fte.)

The Outpatient Children and Adolescent Program at MBHC provides psychiatric evaluation and treatment for children and adolescents with developmental and emotional problems. The goal of the Program is to provide diagnostic evaluation and individual, group and family therapy, as well as medication intervention on either a long-term or short-term basis.

Diagnoses include but are not limited to:

• Attention Deficit Hyperactivity Disorder
• Oppositional Defiant Disorder
• Depression Disorders
• Mood Disorders
• Anxiety Disorders
• Panic Disorders
• Bipolar Disorders
• Post Traumatic Stress Disorder
• Adjustment Disorders

Educational Goals and Objectives (Adult)

During the rotation at MBHC MICA Component of the Glebe Adult OPD, the fellow will have ample opportunity to enhance skills in diagnostic assessment, provide individual, group and pharmacologic treatment of individuals with a variety of substance use disorders co-occurring with one or more other serious psychiatric disorders, as well as teach and supervise psychiatry residents and non-medical professionals.

1. The initial evaluation (psychiatric, medical, psychosocial, and addiction parameters) of patients new to the program.
2. The evaluation of patients with ongoing involvement in any clinic, new psychiatric consultation at the recommendation of requesting psychiatric consultation or seeking psychiatric consultation at the recommendation of the patient’s primary therapist.
3. The assumption of ongoing psychiatric consultation and treatment responsibilities (with supervision) for patients who have been previously followed in our clinics and have a combined substance abuse history and psychiatric illness.
4. The provision of support/liaison to clinic counselor and/or social work staff seeking psychiatric input or supervision.
5. Participation in group therapy in the MICA clinic.

The fellow's responsibilities while here include:

1. Completing three to six combined psychiatric and addiction assessments each week.
2. Formulating and implementing the treatment plans for each patient assessed, following the patients for the duration of the rotation.
3. Obtaining random urine and breathalyzer samples for toxicology screens on all patients in the program, logging results and refusals and communicating those to the other relevant care providers.
4. Participating in substance use groups already established as part of our program as well as initiating and running at least one group that will meet weekly.
5. Preparing two case conferences with supporting literature to be given to the staff.
6. Attend daily rounds, weekly clinical team meetings, biweekly in service conferences and MICA staff meetings.
7. Present and review cases in weekly supervision with the medical director, as well as seek and provide informal supervision with professional staff and trainees as needed.

Educational Goals and Objectives (Adolescent)

Addiction Fellow to become familiar with assessment of youth with substance use problems.

During rotation with child psychiatrist at Westchester Square, Addiction Fellow will:

• Interview/screen high risk adolescents for substance use/abuse
• Participate in treating psychiatric disorders in youth with history of substance use
• May provide individual therapy to 1-2 adolescents with known substance abuse
• May initiate and conduct a substance abuse related group therapy for youths with h/o substance use/or abuse (adolescents to volunteer participation with parental consent)
• Participate in family meetings – of youths with active substance use
• Assist in disposition/referral of teens with active substance use to substance abuse rehabilitation programs when necessary

At the end of rotation at Westchester Square, Addiction Fellow will:

• Write and discuss a case of one patient he/she has become familiar with. Aim is to educate other clinical staff about substance use disorders in adolescents (case presentation to be on Wednesday AM, regular Child Unit team meeting)
• Discuss a review article in reference to the substance used in case presentation

Clinical Rotation Description

Required, 12-month rotation, 0.2 fte. 

Educational Goals and Objectives

1. the evaluation of patients with ongoing involvement in the clinic, now requesting psychiatric consultation or seeking psychiatric consultation at the recommendation of the patient’s counselor or social worker; includes patients with a variety of psychiatric diagnoses.
2. will provide psychotherapy or pharmacotherapy as needed for selected patients.
3. the provision of support/liaison to clinic counselor and/or social worker staff seeking psychiatric input/supervision
4. the provision of support/liaison to clinic non-psychiatrist physicians seeking psychiatric input/supervision
5. The provision of Dual Diagnosis consultation on patients referred from Bronx Psychiatric Center with serious and persistent mental illness (SPMI)

As part of the required training for the Addiction Psychiatry Fellowship Program, fellows are required to go to weekly continuity clinics. Here are the tasks and goals the fellow should be proficient in by the end of their fellowship:

• Carry a full caseload of patients (20-30) including at least one weekly psychotherapy case, new patient intakes and regular medication management patients. (5-10 patients in a given day, both new evaluations and follow-ups to build a minimum caseload of 20-30 patients)
• Must be proficient in proper documentation and filling encounter forms. (This includes being legible.) 
• Able to order labs/tests and coordinate patient care with clinic staff and outside providers.
• Able to order and renew medications for patients that are on DOT.
• Proficiency in board style interview. Fellow should be able to interview patient, do a mental status exam, formulation and assessment/plan and present it to attending physician.
• To participate and run groups. This includes making presentations and associated paperwork.
• To attend IDC and other clinic meetings.
• Fellows are encouraged to prepare educational presentations for staff.
• Fellow will be open to constructive feedback from staff and attend weekly supervision sessions with assigned attending physician.