wondering about. Thanks, Sherry. There might be some content information that we go over, but the sessions now and moving forward are meant to be an open dialogue to help you move closer to your place in the process for implementing contingency management. What it's not meant to be is that I lecture and train and teach the material the whole time. But no worries, we'll kind of transition this session and have a mixture of both, because we know that you had the opportunity to take the healthy knowledge course, that self-paced course about contingency management. And if you didn't have the opportunity to do that, I presented a lot of material last time. I tried to slow it down and pace it for everybody's needs. And there might be some things that we could continue to cover. So with that flavor in mind, what I'm inviting you to consider, and actually, if you'd write it down or type it in your notes, whatever you have access to in front of you, what are three things? And this will be a nice review, and it also helped me not repeat some stuff. What are three things that you recall or know about contingency management? And or if in that list of three, maybe there's some things that you're curious about, you're wondering, maybe skeptical about, because this will help us create the dialogue for moving forward in your process or where you are. So three things that you either know, you remember you're curious about, or even skeptical about, three things. So do that first, and I'll give you some moments to write that down or type it in your notes. So we'll take a pause for you to have the quiet space to do that. Do you mind maybe repeating the question? I think we're having people just hopping on here, maybe that didn't hear it. Perfect. Thanks, Jamie. Thank you for that. Yes. And I wrote it in the chat, but it might get buried in your introductions and saying hello. So thank you. Yeah. Three things that maybe you know or recall about contingency management. Maybe if you want to embed in that three thing or add to it, maybe there's something that you're wondering about. Maybe you want some more information about, or even skeptical about, sure, I'm liking this stuff. And that's a really important part of our conversation around what it is. And if you're skeptical and not sure, you're not going to feel really comfortable moving forward with any kind of process for implementing. And I see some folks already popping things into the chat, and that's great. So don't worry. You don't have to list all three things. But this will give us some collective knowledge and questions maybe in the chat. If you wanted to write one or two things in the chat, that'll start to jumpstart some of our technical assistance conversation about where you are. All right, thanks, Larry. You pretty much gave us a nice, simple definition about it. It's an incentive-based program to help with retention and engagement. It actually helps folks reduce their substance use. So that's a great reminder. Yes, incentives. Prizes and gift cards. So yes, we can use prizes and gift cards, tangible goods to reinforce behavior. Thanks Rachel for adding some specifics around that. We can include gas cards and other types of prizes. The important piece of one of the principles around effectiveness is that it has to be enticing to the person. We always talk about we want to encourage healthy eating, but I don't think folks will be incentivized by health food stores if that's not where they shop. So even though it's well-intended, it might not meet the needs of the folks. Incentives and rewards. So Darian, you make a really nice, and please let me know if I have your name mispronounced. I don't want to mispronounce your name. We have a discernment though between rewards and reinforcement. So when we talk about that in contingency management, reinforcement is what is effective. The reward could be the end of the month when you get your chip at NARA or when you get a certificate for finishing a group. That doesn't reinforce the behavior. Even though rewards are good and we want to reinforce in that way, we use the term reinforcement more in contingency management. And it does help motivate folks in different areas. One thing that if you recall for folks who saw the video, it's not just about shaping the behavior. What else does it help shape if you remember? You could write that in the chat or feel free to unmute. This could be a dialogue, not me reading the chat and talking at the chat either. There's another thing besides shaping behavior, it shapes something else when you watched a video. All right. Thanks, Rhonda. And I'm going to go through the chat unless somebody unmutes or raises their hand, feel free to interject. There's a good comment about the fishbowl, the prize-based reinforcement that, yes, the research tells us at least from what we know now is that it doesn't promote gambling, but we definitely want to be mindful if we're working with someone who has a significant gambling problem, not to use all those bells and whistle terminology that might trigger their gambling. So we want to be mindful of that. Thanks, Amy. That's about a reward. Sorry. The reason I said that about the fishbowl is that people that gamble and then they get a really good prize and it's like, oh, I got to go to the casino because I'm on a hot streak right now. So I guess, like you said, you really have to read your client's health. Sorry, my phone's ringing. I should have put do not disturb. No, thank you very much. It's great to hear your voice, Rhonda, and really highlighting that. We want to be mindful that we might not use that prize-based, see if we have folks that have significant gambling issues, right? Depending on their style of gambling, those fries and that bells and whistles, like you said, might trigger them. Tiffany, thank you so much for that. No worries about the first training. That's a really great question. I have some thoughts. I always will defer to the pat answer of maybe consult with your supervisor kind of answer about the question about do all of them have to take the training? It can be helpful if folks take the training, especially if you have the bandwidth to allow them to do that online training. Then it could be that you start off what you're suggesting. So you already have some ideas about that, Tiffany, that maybe just the core team that are going to be implementing CM, you'll find that eventually the other folks in the space want to know more, are curious about what's going on. I found that it helped me in an organization where everybody had to take the basic training. We were able to understand who didn't want to be part of it. They didn't believe in it because that's a really important piece, don't you think? In any work that you do, if you don't believe in the effectiveness or if you don't believe in the method, you're not going to really deliver it well. I had an adolescent director that said, I don't think it's fair. I don't want to do it. I don't like the notion of offering incentives. And I said, well, maybe you could pause and not implement at this time because I don't want to force you to do it one, two, I don't think it'll work very well if you don't believe in it because it's a positive spin on things. Instead of looking at deficits and what they did wrong, we're looking at the positives and we're reinforcing that. And if you don't believe in it, it might not be effective. Those are some of my points and based on some research and also based on some of my experience as well. Judy, the new thing about safeguarding and SAMHSA's advisory document that I believe Sherry shared last time, and we could probably add it to the chat again if folks didn't see it and would want that or add to our resources. SAMHSA's highlighting, and this is an important thing around safeguarding and protecting your organization because it's a treatment intervention. They're identifying that only folks that are providing clinical care, licensed clinical care, and that's another thing you want to talk with your management team. So that means case managers or peer recovery specialists or support staff can't be delivering it. Now I'm putting air quotes out there, don't want to overuse air quotes, but what it means to me is that how I've handled anything is that the management and the clinical care team are the ones that are determining that a client is appropriate for contingency management any more than a clinical staff member would be deciding that cognitive behavioral therapy or dialectical behavioral therapy is being used. The physician and or the clinical licensed clinician is making a determination about what type of treatment you're going to use for the client. The air quotes then get me to my next comment that it doesn't mean that the other team members aren't involved in the process under the direction of that clinical guidance. At least that's how I would be writing it. Hint, hint, if you wanted to write up policies and procedures, Sherry and I will say that that's not in our purview to write them for you. But just some suggestions around safeguarding is the clinical team is determining the type of treatment the staff can be involved in helping. For example, my support staff at our support staff at the clinic that I worked loved doing the shopping, loved doing the tracking, loved being a part of the team. Peer recovery specialists, case managers can help guide the process and be a part of the delivery of the tangible goods. Those are some examples, but I feel like I'm going on and on and on and I just want to make sure that I'm capturing. We can continue all the conversations if I've gone too far down a rabbit hole and you have other questions. Yes, Chris, positive reinforcement. Again, it's trying to find what's going well instead of what's going wrong. It is a mindset. Thanks Rachel. And that is, I think maybe that's your response to my question or maybe you had that already Rachel that it helps shape the brain too. Is that what you were thinking? All right. Thank you so much. I appreciate the thumbs up and the nod. I was chatting with Sherry earlier before y'all came on and I told her I was reading a book and Sherry read an excerpt of this book called Atomic Habits. You may have heard of it or read it yourself. They're not teaching us much and CJ, sounds familiar to you. Yeah. All right. It may be stuff that we could, you know what I think about? Why didn't we write that book? We know this stuff, but this author, James, his last name escapes me. I don't like to talk about books without giving you the citation, but I was thinking about contingency management from your point, Rachel, that habits are really things that we form in our brain, you know, we automatically walk into a dark room and turn a light switch on as an example. I find that contingency management helps us in the reverse of the habits that using the use of substances has been created a habit by a lot of folks, as we know, and that's what we're trying to work with. All right. Thanks, Tia, for the author, James. I got the first name right. Yeah. So, you know, I'm not here to sell a book. I know I'm jazzed up by it from a lot of perspectives, like why didn't I think of that? Why didn't I write the book and make a New York Times bestseller? Has some good stuff in there related to how we can help people undo old habits and redo new ones, whether you use contingency management and my other hat that I love to wear is motivational interviewing. So I'm doing a, creating a workshop on this book stuff. So I'm all jazzed up by it. I won't, I won't go too far down that lane, but I just wanted to note that my brain is on it. I worked out this morning because I'm changing my habit of not working out and becoming a healthier person. So I was reading the book while working out. All right. Where did I leave off in the chat? All right. And please feel free to unmute if I'm passing over anything. So yeah, that mindset is really important. Taylor can help shift that increased confidence. You know, when folks are early in recovery, you know, we talked a little bit about brains aren't firing on all cylinders. People are healing. They're not feeling good physically, mentally and each little step and man, this James Clear highlights that in the book, each step forward helps to rebuild that habit. I think we have a great opportunity to use our wonderful skills that we already have coupled with contingency management to help that. And yep. CJ, thank you about that. The reward pathways in the brain. That's what this is all. That's what James Clear wrote about that we already knew about. We could have helped him. All right. Yeah, I would, I would imagine Monica in Iowa that having certified counselors would be okay to deliver it. This is an Amy Shanahan sidebar about the safeguard. If it were me and I were the director, I would be ensuring that I document these things in my policies and procedures, who's delivering it. And that then takes us back to the question about who's trained. So obviously if, you know, if someone is delivering it, we want to ensure that we have record that they were trained. Go ahead, Monica. You had unmuted. Maybe you have something to say. Yeah. I just wanted to say that we do have an FAQ document that we have put together that is almost ready to provide to the providers about those questions, because there is a part of Iowa code that specifies like what kind of provider is allowed to provide SUD services. And in Iowa, the agency is licensed and then counselors are either certified or licensed, depending on their credential. And so both certification and licensure in Iowa for an individual clinician should be adequate for a person to serve that kind of clinician role in the CM documentation and stuff. Excellent. Yeah. That makes a lot of sense to me. Pennsylvania I've worked in and New York I've worked in and they're opposite. Pennsylvania, more like Iowa, the agency is licensed in New York. You can have your own credential and qualified health professional license or certification that allows you to do independent work. Yes. Very similar. So it's really how you define it and making sure that you define who's doing what and who can and who can't. So if you do have case managers and other support staff assisting in the project, you could, if you wanted to be clear in your policy or your procedures, it's up to you to add that. But definitely making sure that you're identifying who's delivering contingency management and the training that you provide and the support that you provide. And SAMHSA really, really outlines that in their advisory and any other guideposts around safeguarding. All right. So, Tiffany, so that, so that is that comment new Monica, the, the regarding Tiffany's question, or is that basically what we're saying? Just checking it. Yeah, that's just what we were just saying. Okay. Great. Anything that I missed that you had in the chat that I might've missed? I don't want to miss anybody's comments or questions. So, what are you curious about? What aspects of contingency management maybe feels a little muddy or mucky for you that you'd like to start with, and then I'll revert back to my slides for a bit just to cover some things that you may already know, but just wanted to wrap up some of the things that I prepared last time that is around safeguarding and what can get in the way of implementation. But first, let's see what's kind of muddy or mucky or something that you're curious about that you'd like to start with. I have a question. Yeah, Taylor, go ahead. How do we provide the, or what would be some examples for contingency management when we don't have like the SOR funding, right? So it's just solely treatment-based. What would be some examples that we can provide, air quote, the contingency management that are not funded within that $750 budget? That's a great question, Taylor. And please, folks in the room, you might have some ideas and answers and suggestions. So please share them in the chat with Taylor, because technical assistance isn't all about just me being the, you have experience, you've been there, maybe you have some thoughts and have tried things on too. So it's all of us together that can help bring the information to the table. So Taylor, a couple things that come to mind for me, privileges, clinic privileges, talking to your financial officer, writing a proposal to use clinic funds, perhaps. I think your whole state would have to get the 1115 waiver, and then you have to go down that, which is a process where you could bill Medicaid and Medicare. So that's a bigger deal, but I have to put it on the table, why not? I love having been in these meetings, like, why are people talking about this 1115 waiver? I have no idea what they're talking about. So it's really just one of those state things that the state agency has to apply for the state to be able to bill Medicaid and Medicare for certain things, and that are outside of the scope that you're already working under, just to simplify it. Now I have worked with organizations, I know ideas are popping up, so go ahead and put them in the chat. And when I brainstorm, you can maybe think of things too, folks, it's up to you. When I worked with other organizations who received donations, they wrote a nonprofit letter and sought out vendors to donate goods. That you have to be really mindful of, not trying to give advice, but just talking about safeguarding, where you are consulting with your management team about the ethics and all that around that related to your own policies and procedures. And also then, so for example, if I'm in your CM program and you receive donations that somehow you're tracking, if that's not your only stream of where you're getting goods that you're tracking, that Amy Chan spent down $200 from this grant, so grants another lit thing on the list, or donations that you received from a local church or a local organization that you're tracking that inventory. So that's where it can get a little wonky, but those are some ideas. What are your thoughts about some of that? I can get really specific Taylor and share that, um, you know, I was all jazzed up. I was the administrator of several different outpatient programs, including methadone outpatient perinatal program. And I was like, I can't believe we're not using CM. And I had the same issue that you're bringing up. Um, I can't just spend money cause I want to, so I wrote up a proposal, very simple proposal about what contingency management is, why I was doing it, what the problem was within the particular clinic or clinics that we were trying to address, i.e. attendance or continued use of stimulants while on methadone, for example, um, you know, my financial officer didn't care much about the details, but my clinical directors wanted to know why. And I wanted to back it up with evidence. And I offered some citations of the research and shared some simple things like that. And you know, basically did a cover letter, Hey, I want some money and this is why, and then here's the details. I learned that a long time ago, management doesn't want the details first, tell them what you want first. So, um, I, I offered up a proposal and said, Hey, can I pilot this? And I got a thousand dollars for each clinic, three clinics to spend over three months. And then I mindfully collected the data and told the story back so that hopefully I could continue to use my own budget money, or I could budget money. If you would towards this, I didn't want to wait for other things. I'm impatient that way. That was about, uh, 15 years ago. So two out of the three of the clinics, um, um, did some sick, had some success, a lot of success actually. Um, and we're able to do some standard operating procedures and made contingency management, one of the treatment programs that they offered on top of other things that they did. Thank you. You're welcome. All right. Thank you, Rachel. You added in there the, um, some, uh, previous conversations around clinic privileges. Yeah. Those are Taylor's original ideas, just giving them right back at her yesterday and they're really good. Well, I told you, I thought you already had some ideas. So there you have it. You, I was right. Now I feel good. All right. Yeah. So good ideas. Um, just, you know, try to keep them coming. And I think that that's the really power of having other team members involved. Maybe they can't deliver clinically the CM, um, but boy, folks have a lot without our support staff, our support team had great ideas and great energy around being a part because especially for folks who work in a methadone clinic, the front staff, the nurses, they see people every day and then feel disconnected from the clinical team. So this really brought them in to the fold of being really being part of the team. Thanks Monica for clarifying the 1115 waiver. Yeah, uh, same thing, Darian. You know, it's either you find the support locally, maybe through your counties or through your agency and, or great to get it through the state as well. Ah, Judy, that's a great question. You know, that's a big thing that I talk about when I talk about motivational interviewing and motivational incentives, or now we really want to hone in on its contingency management, which is evidence-based behavioral therapy. Um, if someone's doing good with their sobriety, if that's what their goal is to be sober and not use, they're not ambivalent. A lot of times contingency management specifically works well at the onset of care when they're struggling, when their brains are healing, when they're not sure they want to commit to this lifelong pursuit of being sober, whatever, however they define that. I hope that helps Judy. Um, and, and your other part of your question, or maybe that's your primary part. What does it look like for these individuals? So just like I might not use cognitive behavioral therapy for everyone, I may not use CM for everyone. That's one answer. Another answer could be that maybe the individual would benefit from treatment goals. I say that because I believe in it. And I also want to caution that we don't have robust research that says, although Nancy Petrie writes about it in one of her articles that we cite in the slides, and we'll share that with you as well. She does, um, offer examples around other goals, other life goals, you know, an organization that I worked with, reinforce someone's behavior to prep them to take their GED, you know, big goal, James Clear talks about that in his book, you want to become a, a, a studier or a student, not necessarily the outcome always, you know, sometimes it's hard to reach the outcome of obtaining your GED. So that's where I like in a lot of what James is writing about to contingency management that it's those smaller steps. So those are some thoughts I have, Judy, about other things that you could use CM for, for folks who are already on, on a good path, but they're struggling with other things, but make sure you consult with your management team and who's leading the CM show. Because if we go off the, what, what research says, sometimes folks are not, um, not using CM for that. And we're shifting to using motivational incentives. And that's a whole nother conversation, whole different ball of wax, right? We're just enticing them, helping them overcome their hump. Go ahead, Judy. So, yeah, that's what I, a lot of my individuals are, are doing very well, um, that are on the SOR grant. Um, and those are the individuals that I looked across to see if, you know, out of the 16, you know, only four would really benefit from something because the rest are doing well, you know, before it was, you could come for three appointments and everybody did that, you know? Um, so if I'm understanding you correctly, if I have an individual that, um, even though he's been, you know, he's sober and he's maintaining his sobriety, he deals with, um, um, anxiety, um, so bad that I, I said, maybe this could work with, you know, a goal of going outside and cutting grass in the past. If he cut grass, he would wonder if somebody's talking about him or where's his wife, things like that. Is that something that could be, as long as myself as a peer recovery coach, as long as I could monitor it, is that something that is, is considered, um, contingency management if it's, it's based off of that? You're on the right path, Judy. And I would say though, that now SAMHSA is really clarifying for us that contingency management is a treatment intervention because even by itself, it can be that needs to be delivered by somebody who's licensed to do that. And I, and I'm just going to compliment your passion and, and, uh, interest that that would fall in the category of motivational incentives, which I, if I were doing that myself, I would write that I'm using incentives to help people achieve some life goals or some treatment goals. But it would not fall under the contingency management. I know we're splitting hairs here. I used to use the terms interchangeably, but we're pretty clear now that contingency management has some specific principles and guides where it, it gets often miscon, misinterpreted and confused with offering people an incentive to take a test, to go to an AA meeting, to, um, like you said, step outside and cut the grass. So I would work with my treatment team and, and maybe the directors and managers around are they also supporting motivational incentives? And if so, um, probably document and separate them out very specifically. And I hope, I hope that helps. It might spark some other thoughts or questions from others as well. And thanks, Sherry shared a link that there's some, I love the word sweet, um, produced by Nada and Sam. So there's some materials there that might spark other ideas and be tools that you can adapt from, or maybe use in your work moving forward. Other thoughts or questions? I'm going to share my screen and show some slides just to cover some things that you may already know. Maybe it'll spark some other questions and it gets into the nitty gritty of the things that we have to consider when we're implementing, more than I'm coming in to lecture you about anything more, but it really kind of gets us into these conversations that we're having together about, well, what about this? What about that? I have my screen up and I think we had landed on this slide about what people say. And we're talking a little bit about that, but I'll stop here for a second just to share on that wonderful question of who has to go through the training. When you have everyone involved in what we're doing, then they understand and someone who doesn't have a clear answer might know who to refer a client to, or a person to who might have a question about things. So I know for me, it really reminded me and I knew throughout my whole career, I needed to be reminded over and over again that the support staff, the folks that clean the clinics and other folks in our midst have relationships with our clients too. And it's good to, if in any way we can involve them in the conversation, especially when we're starting something new. For example, the support staff were stocking our prize cabinet, if you will, and people were wondering what the heck it was. And we realized how many people didn't know what was going on because when they saw these new things coming in the clinic and new conversations that we were having, it can make others feel outside of the team. So that's just my own experience there. But this was all about the conversations about what people say. The clients are having positive stories to tell. The staff are feeling like they have a tool to, instead of being deficit-funded, not deficit-funded, deficit-focused, focusing on the problems, you can start to hear the joy in their voices too as a parallel process. They also feel the joy in being able to recognize good things going on in the clinic and those smaller successes that help to create healthier habits. Things that could go wrong, I may have covered this last time, and I won't go over these unless you have any specific questions. But I will say that we do have a checklist of the principles and it has even more specific things in it. But typically what we've noticed that if it seems like contingency management isn't working well, it's because we're not following those principles. So I have one clinic example in our perinatal clinic. The director didn't think it was fair to not reinforce everyone to show up for their appointments. And that really speaks to your question, Judy, when people are doing well, they don't need the incentive. They don't need the reinforcement. Yeah. Makes sense, doesn't it? We feel that way. I'm good. I mean, I would like to get gifts every once in a while, but I don't need you to reinforce my behavior. And what ended up happening in that clinic, and I think it was a good lesson to go down, an expensive one, didn't break the bank, but she spent the money down really fast and her numbers didn't really tell us a story because she was incentivizing everybody to show up and the same data was really there. Only about 30% of the people were not consistent showing up for their appointments and that kind of stayed the same. So we didn't have a good, robust story to tell about the effectiveness of contingency management. So I just thought I'd offer you all an example that I had from my experience. So that checklist I trust is in that suite of goods that Sherry just shared in the chat and or we have a copy of it that we could share with you. There's seven principles of behavioral modification and those principles guide our effectiveness of using contingency management. And feel free as I'm going along, if you want to unmute, if you have comments or questions and or you want to use the chat box, that's up to you because now we're going to get into the concerns and the safeguarding. I trust that many of you have already started to think about these things based on your questions. So you already brought up the financial concerns, Taylor, you had that question about, well, how do I do this? I don't have money. That's a big issue. Yeah. It's not just about money. It's about resources. And so to me, that was the important piece about, you know, even though I was the administrator of the clinics that I was serving, I needed some support from my upper management. So I had to do more selling, if you will, of the program. And also the staff involvement, the time it took to be trained to do these, some extra things involved. For me, it was super helpful because we had real champions just rise up, really believed in this and really wanted to do it and didn't mind doing it. And of course, they would have liked an incentive to do it because it was extra work. So can we give them incentive to do it? I don't know. It's up to you and your management team. Or do they get some sort of privilege, protected time or some kind of something for their work? That's really something to consider when you're going to implement. Certainly how do you embed it in your current system? Judy, you have beautiful questions and you're not the only one that's going to have a question like that. Why can't I use incentives for my folks that are doing well? Why can't I be the one that delivers it with the people that I'm serving? So that's where the training, all staff can be beneficial. Not that they'll remember all of that. We have to document it. It's a treatment intervention and we're going to get into that with the safeguards. I already mentioned it, Monica, I think you're already on track. You were talking about a FAQ that there's some documented efforts about what you're doing and why you're doing it. Political stuff is important too. I never thought so. When I became an administrator, I was like, policies and procedures, oh my gosh. I never wanted to read them and I certainly didn't want to write them. But they are important. They are important. I'm speaking real here. They are important. We have to say what we're doing and why we're doing it, which really to me ties into this last piece about philosophies. In one of the clinics, like I shared, my philosophy about thinking positive and incentivizing and reinforcing someone's good behavior wasn't the philosophy of some of the team members, some of the staff members. It's hard for me, but I have to settle in and put on my acceptance hat and invite people to have that conversation because I was once there too, skeptical, wondering. It's not what I believe. For me, I don't know about you all, but for me, I wanted to welcome those conversations and I welcome you to have them too because it's not going to go away if we ignore it. That's been my experience. I heard of a guy in New York, City Health and Hospitals, big system. He didn't want to do it and it took two years. He told his own story. It took me two years when my clients were going, how come I can't? How come you're not? It's like, I just didn't really buy into it, but then I started to see it work time and time again and people were excited and I was ready to absorb the information and go, maybe there's something to this. There's something to be said for our traditionalists. At the same time, this is my plugin for culture and stigma. We have a deep-seated culture in addiction care and substance use disorder care where we shake it off, come on, pick up your bootstraps, stop doing that, despite what research says. Our mental models are hard to deconstruct. Our beliefs about something are hard to change sometimes, no matter how long we've been around the block. That's been my experience allowing for these conversations to happen because otherwise then I've learned that staff bring it up anyway and they bring it up at the water cooler or they bring it up in the hallway or they bring it up in their team member's office and they're meh, meh, meh, meh, meh, and misinforming. The better informed we are, and I would say to folks, if you don't believe in it, don't do it. It's just that simple for now. Don't do it for now. And then tracking not only falls into that, the resources, but also that whole mentality and agency quality improvement process. I know that when I was working predominantly on the front lines in the field, I never received my data. I never knew if what I was doing was working. I never knew that there was data, let alone did I see it. And now because of our electronic world and our access to data and material and information, I would say it's really important and it really helps. We had a horse race kind of thing in our staff room and people would put up, not protected health information by any means, but would put up initials or symbols to show how folks were doing so that they could all see that their hard work was starting to pay off. So that's an important thing, not just from a financial, logistical, regulatory thing. It's certainly important from a philosophical thing. If people don't believe it's working and they don't see that it's working, then they'll never buy in or never think that it's an effective treatment intervention. So very simplistically, I have some bullet points here on the slide that you could see. And Sherry offered up in the chat, the link to the advisory from SAMHSA, who outlines what their expectations are. So here are some things, and instead of talking about them, I'm going to let you digest them, take a look at them and see if you have any questions about any of these and need clarification for them. Amy, the second bullet about abstinence and drug testing, can you talk through that one a little bit? So it's not necessarily a prerequisite that they have 100% abstinence from all substances in order to participate, right? That might be part of their plan to get to that. Oh, absolutely, yeah. So I think, Monica, this point speaks more to, because we do know you can extinguish someone's one substance that they use and they don't stop using others. Now that could be construed as a health optimization harm reduction approach. At the same time, we know that if that person identifies that stimulants is their problem substance, and that's the one they wanna focus on, then that's where we meet them, even if they might be smoking marijuana or drinking alcohol. Did I get that right? I didn't wanna say smoking alcohol. I'm talking really fast, just seeing if you're still paying attention. So this is more about if you're targeting abstinence, it is highly recommended that you use point of care testing, meaning you use instant kits to test the urine sample because it's less effective when you're sending that sample out to a lab and you don't get it for two, three, four days, it diminishes the effect of contingency management. So it's not necessarily, Monica, about the different types or which target substance you're targeting, it's point of care drug testing. And do you also, or have you talked about if, because the point of care tests tend to be slightly less accurate, if someone argues with the outcome of the point of care testing, say it's a false positive, and they say, no, I didn't use, I don't know why it's showing that or whatever, sending it out for confirmation, is that something that, how does that fit in with contingency management because it will delay the whole situation? That's a great question that comes up a lot. So the California Project, and I think Sherry and I might have access to some of that information. It might be even in the SAMHSA advisor. I haven't read it in a while, so I don't retain all the details, but there are some specific companies that have more effective point of care testing. So there's one recommendation there that you consider investing in a more valid test. Another thing to consider, Monica, to your question is to write up what your decision plan is if that happens in your clinic. Because what will happen is if you don't have that in your procedures, it'll become a per person decision-making how to handle it. And that could break down the effectiveness of contingency management. So it's already part of the agreement with you and the client. And everybody has the same, is where my quality improvement hat of consistency comes in, that if that's something that you'd consider, if any point of care test tests positive, we will delay reinforcement and send the urine specimen out for a test at the lab. Or you might say every point of care test that tests will also send it out for the lab, no matter what. There's a couple of things here from background stuff. If you don't have a waiver to read the test, you can't use that point of care testing clinically. And I hate to use those fancy words like CLIA waiver. I never knew what that was until I went down this path of contingency management. But technically it says, you cannot read the results of the lab. Even though you could see the bar that says positive for cocaine, you're not allowed to read it if you're not trained to read it. So it's a lab kind of protocol thing. So I've talked with other folks that we would talk about, if you do point of care testing, can you make it a standard procedure that you also send it out to the lab for testing? So you use it for contingency management, and then you send the specimen out for clinical reasons. Long answer to your question, Monica. I hope that was helpful. So you can write it up the way you intend on using it or how you intend on handling false positives, false, there can be false negatives as well. So I have found predominantly and certainly not, this is not, I'm generalizing that people just want to be true for what's going on. And if they really use, they'll say so. If they're not going to tell you that, they're afraid of something, right? And don't want to get in trouble, don't want to lose their incentive. But kind of all that kind of cultural nuance starts to melt away. And I often share the story of the gentleman who was targeted for attending group and he showed up late and the clinician didn't notice it. So he got his incentive anyway, something like that. I think I'm telling the story right. And the client was sitting in group and he fessed up and he said, you know, Judy, you didn't notice that I showed up late. I'm going to give my incentive back. And then one of the other clients said, oh, I'm going to give you my incentive for being honest. So it really kind of has this ripple effect of positive reinforcement around any kind of behavior that we're familiar with seeing. I'll just leave it at that. All right, we're winding down, last three minutes. Any lasting questions or comments? We have two guides here that we can share with you. One for implementing and one has a competence scale for the team that you may be training. There are larger documents if you're interested in those. I think Nancy Petrie was author, co-author of one, if not both. So she's one of the researchers of the Fishbowl. So we'll share that research or those articles along with other resources that we have. And then here are the final kind of bullet points of consideration that you may have already considered, already had on your to-do list. So who's going to be a part of it? That was part of our conversation. Who's going to assist? The Judys and the others in the other world can be a part of this. We don't have to exclude the non-licensed clinician because as you saw in the document that they're to assess, do the assessment. Definitely Taylor brought up the budget needs. We started off with some training needs. Who needs to be trained and what materials are you going to use? All right. I'm going to stop sharing my screen and- We've got, do you have the evaluation survey link? Oh, yeah. Thank you, Sherry. I always need you to remind me. There's a really important slide. This is how Sherry and I continue to be able to work with you as if you give SAMHSA and us feedback about how we're doing. So if you want to use your phone and take a picture of that QR code or use that link, we really thank you so much for your time, your energy, spending this hour, and then also completing this quick survey. Yes. Thank you guys so much for taking a moment. I just dropped the link. So if you're at your desktop, you can use your computer mouse to click on the link. That will take you to the evaluation survey or you can use your phone to use the QR code here. However you choose to connect with it, we really hope you will complete the survey evaluation. It helps us know if we're on the right track, if we're giving you the kinds of support that you need to be able to do the work that you're doing. And yeah, we just really appreciate you taking the time to do that. This has been a really great session. I want to thank Amy for her expertise and her ability to answer questions to stop the cuff so easily. And I'd like to remind you all that we're going to have a third session, which is set for Tuesday, April 22nd, from nine to 10. Same Zoom link as you use this time. And this is going to be another consultation session. So Amy won't be providing any training or didactic information. We want you guys to bring your questions, your case scenarios, your concerns. If you have any doubts about the work, if you are skeptical of any aspect of it, we want to hear that and give Amy a chance to kind of address any of those things. So we'll look forward to seeing you all again on April 22nd. Yeah. Could I jump in really quick too and just say, there's a few names in the chat that we need the agency for that we're not sure, I assume they're clinicians at one of the agencies that we don't know your information. So if you could check the chat before you hop out and make sure that if your name is in there, that you get us your agency information, that would be great. I have one more thing to add to Sherry's list of things to bring next time. You could also bring your stories of what you've already started. Maybe you've experienced this. Maybe you're having a hard time with something. They could be good. They could be, but share your stories because that's really the robust piece of how we move forward together. So thank you for considering that too. Thanks everybody. Thanks for your time. Take care. Enjoy the rest of your day. Bye everybody. Bye.

contingency management

treatment settings

incentive-based program

substance use reduction

staff training

cultural considerations

financial constraints

implementation policies

interactive discussions