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New Application: Addiction Medicine

Training & Accreditation Committee


The Addiction Medicine Foundation

INSTRUCTIONS
All text boxes in this form may be expanded as necessary.
Include the following attachments (labeling each by number):
1. Program Letter of Agreement (PLA) for each participating site in which fellows receive required
training.
2. Program Director and physician faculty CVs.
3. Overall educational goals for the program.
4. Policy for supervision of fellows (addresses fellows responsibilities for patient care and
progressive responsibility for patient management and faculty responsibilities for supervision).
5. Program policies and procedures (duty hours, work environment, moonlighting, due process).
6. Copies of instruments that will be used:
6a. by faculty to evaluate fellows at the completion of each assignment
6b. by faculty to evaluate fellows at the completion of training
6c. by fellows to evaluate faculty and the program.

Please email the application and attachments to: adanzo@addictionmedicinefoundation.org


AND
Mail the signed application form to:
Andrew Danzo
University at Buffalo Dept. of Family Medicine
77 Goodell Street, Suite 220
Buffalo, NY 14203

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New Application: Addiction Medicine
Training & Accreditation Committee
The Addiction Medicine Foundation
SPONSORING INSTITUTION [I.A]
Sponsoring Institution Name*
ACGME Code (sponsor number)
Designated Institutional Official
*Enter name as it appears on the ACGME listing of sponsoring institutions:
https://apps.acgme.org/ads/Public/Reports/ReportRun?ReportId=16&CurrentYear=2016&USStateId=

FELLOWSHIP
Fellowship Program
Name
Mailing Telephone
Address
E-mail Web address

Number of fellowship positions requested


Planned start date for first fellow(s)

Name of the residency program(s) with which


the fellowship is associated [I.A.2 & 3]
Residency Program Director

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

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

SIGNATURES
Designated Institutional Official

Name Signature Date

Fellowship Program Director

Name Signature Date

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

Site 1: Primary Teaching Site


Name
Address

Is site under governance of the sponsoring institution? YES NO


Duration of experience at this site (total for all rotations, in months or weeks)
Briefly describe the content of the educational experience at this site, addressing faculty coverage,
volume/variety of clinical experience, and educational impact (up to 250 words)

Site 2
Name
Address

Is site under governance of the sponsoring institution? YES NO


Is the experience at this site REQUIRED ELECTIVE BOTH
Duration of experience at this site (total for all rotations, in months or weeks)
Briefly describe the content of the educational experience at this site, addressing faculty coverage,
volume/variety of clinical experience, and educational impact (up to 250 words)

Site 3
Name
Address

Is site under governance of the sponsoring institution? YES NO


Is the experience at this site REQUIRED ELECTIVE BOTH
Duration of experience at this site (total for all rotations, in months or weeks)
Briefly describe the content of the educational experience at this site, addressing faculty coverage,
volume/variety of clinical experience, and educational impact (up to 250 words)

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

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PROGRAM PERSONNEL AND RESOURCES
Program Director [II.A]
Does the Program Director have a minimum of 0.1 FTE protected time to carry out the educational,
administrative, and leadership responsibilities of the fellowship? ..................................... YES NO

Explain if NO:

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

Name, Degree(s)
Department
Faculty Rank
Mailing Address

E-mail Phone Phone


(office) (mobile)
Primary Specialty (ABMS)
Subspecialty (ABMS)
Addiction Medicine certification CURRENT PENDING NEITHER
Addiction Psychiatry certification CURRENT PENDING NEITHER
If you do not have addiction certification but are certified in
another subspecialty that incorporates training in addiction
medicine, what is that subspecialty?

Physician Faculty
(add rows if needed)
Name, Degree(s) Department and Rank Primary Board Subspecialty
(eg, Prof, Clinical Asst Certification(s) certification(s)*
Prof, etc)

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

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

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

Other Program Personnel


Coordinator
Name Phone E-mail

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

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

DUTY HOUR, PATIENT SAFETY, AND LEARNING ENVIRONMENT [VI]


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

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

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

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

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

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


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

Competence in providing care to patients in different settings such as inpatient medically


managed withdrawal programs, substance use disorder treatment programs, consultation
services and integrated clinics .............................................................................. YES NO

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

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

The ability to work with an interdisciplinary team that could include other medical specialists,
health care providers, counselors, psychologists, family members and other stakeholders
involved in the patients care ................................................................................ YES NO

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

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

Medical Knowledge [IV.A.2.b]


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

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


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

Pharmacology of common psychoactive substances, including alcohol, nicotine, stimulants,


sedative-hypnotics, depressants, opioids, inhalants, hallucinogens, and cannabinoids
.............................................................................................................................. YES NO

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

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

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

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

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

Comprehensive substance use assessment including diagnostic interview, use of standardized


questionnaires, lab tests, imaging studies, physical examinations, mental status examinations,
consultative reports and collateral information ....................................................... YES NO

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

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

Medication assisted therapies and psychosocial interventions for SUDs across the age
spectrum ............................................................................................................... YES NO

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

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

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

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

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


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

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


Will fellows be expected to:
Work collaboratively with other providers and allied health professionals, including physicians,
nurses, social workers, counselors, and pharmacists to care for patients with substance-related
disorders .............................................................................................................. YES NO

Work collaboratively as members of inter-disciplinary teams as a consultant and as a team


leader ................................................................................................................... YES NO

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

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

Professionalism [IV.A.2.e]
Will fellows be expected to:
Demonstrate competence in recognizing and appropriately addressing biases in themselves,
others, and the health care delivery system ......................................................... YES NO

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

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

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

Demonstrate the qualities required to sustain lifelong personal and professional growth
.............................................................................................................................. YES NO

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

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

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

Practice flexibility and maturity in adjusting to change with the capacity to alter ones behavior
.............................................................................................................................. YES NO

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

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

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

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

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

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Systems-based Practice [IV.A.2.f]
Will fellows be expected to demonstrate the ability to:
Advocate for quality patient care and assist patients, employers, programs, agencies and
governments in managing system complexities, including an awareness of heightened stigma
associated with addiction and other systemic barriers to obtaining addiction services.
.............................................................................................................................. YES NO

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

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

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CURRICULUM ORGANIZATION AND FELLOW EXPERIENCES [IV.A.3]
Enter the approximate number of hours per month (and total in last column)
1 2 3 4 5 6 7 8 9 10 11 12 Total

Outpatient
rotations
Inpatient
rotations
Electives

Continuity
Outpatient
Learning
Experience

Clinical Rotations: Outpatient


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

Explain if NO (up to 400 words):

Outpatient Rotation 1
Rotation Name Clinical Site (Name and #) Length Faculty supervising

Briefly describe the training experience, including setting, activities, patients (up to 300 words)

Copy and add Outpatient Rotation boxes as necessary

Clinical Rotations: Inpatient


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

Explain if NO (up to 400 words):

Inpatient Rotation 1
Rotation Name Clinical Site (Name and #) Length Faculty supervising

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Inpatient Rotation 1
Briefly describe the training experience, including setting, activities, patients (up to 300 words)

Copy and add Inpatient Rotation boxes as necessary

Longitudinal Continuity Outpatient Experience


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

Longitudinal Continuity Outpatient Experience


Clinical Site (Name and #) Faculty supervising

Briefly describe the training experience, including setting, activities, patients (up to 300 words)

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

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

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

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

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

Longitudinal Learning Experience


Will fellows have at least 4 hours per week devoted to longitudinal learning experiences [IV.A.3 (1)]
......................................................................................................................................... YES NO

Please describe (no more than 400 words)

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

If NO explain (up to 400 words)

Identify electives offered:


Name Site Length Faculty Brief description (up to 300 words per
# (weeks) supervising elective)
1
2
3
4
5
Add rows if needed (number consecutively)

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

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

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

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

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

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


Provide the methods of evaluation used for assessing fellow competence in each of the six
required ACGME competencies and identify the evaluators for each method (e.g., performance
in patient care is evaluated by global forms completed by faculty, observed histories and
physicals by the ward attending and the continuity preceptor; medical knowledge is assessed
through an open-book in-training examination and an evidence-based journal club evaluated by
the PD, etc.)
Examples of assessment methods: direct observation, videotaped/recorded
assessment, global assessment, simulations/models, record/chart review, standardized
patient examination, multisource assessment, project assessment, patient survey, in-
house written examination, oral exam, objective structured clinical examination,
structured case discussions, anatomic or animal models, role-play or simulations, formal
oral exam, practice/billing audit, review of case or procedure log, review of patient
outcomes, review of drug prescribing, fellow experience narrative and any other
applicable assessment method

Examples of types of evaluators: self, Program Director, medical student, faculty


member, nurse, allied health professional, patient, other residents/fellows, technicians,
clerical staff, evaluation committee, consultants

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Competency Assessment Method(s) Evaluator(s)
Patient Care

Medical Knowledge

Practice-based Learning &


Improvement

Interpersonal & Communication Skills

Professionalism

Systems-based Practice

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